childhood emotional maltreatment, depression, and eating

CHILDHOOD EMOTIONAL MALTREATMENT, DEPRESSION, AND EATING

DISORDER SYMPTOMATOLOGY: EXAMINING THE ROLE OF EARLY MALADAPTIVE

SCHEMAS

by

ERIN ELIZABETH BURNS

(Under the Direction of Joan L. Jackson)

ABSTRACT

The present study examined the role of early maladaptive schemas in the development of

depressive and eating disorder (ED) symptoms among college women with a history of

emotional maltreatment. Participants were 996 predominately Caucasian female students who

completed a questionnaire packet pertaining to the constructs of interest. Structural equation

modeling analyses support a model where the relationship between emotional maltreatment and

ED symptoms is indirect through the influence of schemas and depression. Although women

endorsing a history of emotional maltreatment reported significant associations with multiple

schema domains, the strongest association was observed between the Disconnection & Rejection

domain. Although preliminary, results support the use of schema therapy with individuals

endorsing a history of emotional maltreatment in an effort to ameliorate depressive and ED

symptoms. Findings contribute to efforts to understand the sequelae of emotional maltreatment,

arguably the most prevalent, yet understudied form of child maltreatment.

INDEX WORDS: Emotional maltreatment, Early Maladaptive Schemas, Depression, Eating

Disorders


DISORDER SYMPTOMATOLOGY: EXAMINING THE MEDIATING ROLE OF EARLY

MALADAPTIVE SCHEMAS

by


B.S., James Madison University, 2004

M.S., University of Georgia, 2009

A Dissertation Submitted to the Graduate Faculty of The University of Georgia in Partial

Fulfillment of the Requirements for the Degree

DOCTOR OF PHILOSOPHY

ATHENS, GEORGIA

2012

© 2012

Erin Elizabeth Burns

All Rights Reserved


DISORDER SYMPTOMATOLOGY: EXAMINING THE MEDIATING ROLE OF EARLY

MALADAPTIVE SCHEMAS

by


Major Professor: Joan L. Jackson

Committee: Sarah Fischer

Anne Shaffer

Electronic Version Approved:

Maureen Grasso

Dean of the Graduate School

The University of Georgia

August 2012

iv

DEDICATION

To my parents, Anna and Edward Burns, whose wisdom, generosity, and enduring

support made this achievement possible. Thank you for planting the seeds not once, but countless

times.

v

ACKNOWLEDGEMENTS

I would like to sincerely thank Dr. Joan Jackson for her support and guidance with this

project. Throughout my graduate studies, her commitment to my development as a researcher

and clinician has been invaluable. She has remained actively engaged as my mentor for more

than five years. Although the frequency of my contact with her will decrease after my

graduation, her influence personally and professionally will remain with me indefinitely. With

respect and gratitude, I wish to extend my heartfelt appreciation. I would also like to recognize

the contribution of my committee members, Dr. Sarah Fischer and Dr. Anne Shaffer, for their

valuable feedback and support on this project and throughout my graduate career.

vi

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS......................................................................................................... v

LIST OF TABLES .................................................................................................................. viii

LIST OF FIGURES ................................................................................................................... ix

CHAPTER

1 INTRODUCTION ..................................................................................................... 1

Overview ............................................................................................................. 1

Childhood Emotional Maltreatment ..................................................................... 3

Depression and Eating Disorder Symptomatology ................................................ 8

Child Maltreatment and Eating Disorder Symptomatology ................................. 10

Early Maladaptive Schemas ............................................................................... 17

Summary ........................................................................................................... 28

2 RATIONALE AND HYPOTHESES ....................................................................... 31

Significance ....................................................................................................... 32

Hypothesized Model .......................................................................................... 35

3 METHOD ................................................................................................................ 38

Participants ........................................................................................................ 38

Measures ............................................................................................................ 38

Procedure ........................................................................................................... 42

Data Analytic Plan ............................................................................................. 43

vii

4 RESULTS ............................................................................................................... 50

Sample Characteristics ....................................................................................... 50

Measurement Model .......................................................................................... 53

Structural Models ............................................................................................... 55

5 DISCUSSION.......................................................................................................... 67

REFERENCES ......................................................................................................................... 74

viii

LIST OF TABLES

Page

Table 1: Description of the Young Schema Questionnaire ........................................................ 30

Table 2: Means, Standard Deviations, and Bivariate Correlations of Study Variables ................ 52

Table 3: Summary of Model Fit Indices .................................................................................... 54

ix

LIST OF FIGURES

Page

Figure 1: Hypothesized Structural Model .................................................................................. 37

Figure 2: Measurement Model ................................................................................................... 46

Figure 3: Structural Model 1 ..................................................................................................... 56






1

CHAPTER 1

INTRODUCTION

Overview

A history of child maltreatment (e.g., child sexual, physical, and emotional abuse, and

neglect) has been associated with increased rates of a variety of psychological and physical

difficulties. Efforts to dissect the multifinality associated with abuse outcomes have initiated a

wave of research focused on examining the underlying mechanisms driving the association

between abuse and subsequent psychopathology. For example, there is evidence that several

factors mediate the relationship between child maltreatment and adult maladjustment, including

negative cognitive style (Gibb et al., 2001; Hankin, 2005), insecure attachment (Hankin, 2005),

emotion dysregulation (Gratz, Bornovalova, Delany-Brumsey, Nick, & Lejeuz, 2007; Burns,

Jackson, Harding, 2010; Tull, Barrett, McMillan, & Roemer, 2007), and experiential avoidance

(Tull, Jakupcak, Paulson, & Gratz,, 2007). Consistent with this research, the current study

investigated the role of early maladaptive schemas (EMS; Young, 1994, 1999; Young, Klosko,

Weishar, 2003) in the development of depressive and eating disorder (ED) symptoms among

college women with a history of emotional maltreatment.

The second objective of the current study was to examine the unique contribution of

emotional maltreatment as it relates to the development of eating disorder (ED) symptoms.

Efforts to elucidate pathways linking early adversity to psychopathology are consistent with

Beck’s content-specificity hypothesis. According to this hypothesis, psychological disorders and

states ought to be “differentiated by the content of their cognitive associates” (Beck, 1976).

2

Given that recent research has provided preliminary evidence for the association between

childhood emotional abuse (CEA) and eating disorder (ED) behavior (Fischer & Hartzell, 2008;

Grilo, Masheb, Brody, Burke-Martindale, & Rothschild, 2005; Kent & Waller, 2000; Kent,

Waller, & Dagnan, 1999; Mazzeo & Espelage, 2002; Messman-Moore & Garrigus, 2007) the

current investigation sought to extend previous findings by investigating the collective impact of

emotional abuse and neglect.

In addition to examining the relationship between emotional maltreatment and ED

symptoms, depressive symptoms were included in the overall model for several reasons. First,

several studies suggest that emotional maltreatment is strongly related to depression, with recent

evidence indicating that emotional maltreatment prospectively predicts the onset of depressive

symptoms (Liu, Alloy, Abramson, Iacoviello, & Whitehouse, 2009). Second, clinical and

epidemiological studies reveal substantial comorbidity across eating and depressive disorders

(Hudson, Hiripi, Pope, & Kessler, 2007). Third, negative affect, also referred to as “associated

mood changes” is included in cognitive behavioral models of bulimia and binge eating as

potential factors that increase propensity for ED behavior (Fairburn, 2008). Lastly, initial

research supports the association between EMS and depressive symptomatology (Lumley &

Harkness, 2007; O’Dougherty Wright, Crawford, & Del Castillo, 2009).

Finally, by examining the predictive value of EMS on the development of ED behaviors,

this study aimed to examine how experiences of emotional maltreatment initiate the development

of specific maladaptive schemas, which perpetuated throughout young adulthood, give rise to

specific maladaptive coping strategies in the form of ED behaviors. Ultimately, by identifying

particular schemas predictive of ED behavior, then efforts to target specific schemas in cognitive

therapy may facilitate treatment with abuse survivors. Finally, a brief literature review of

3

childhood emotional abuse, early maladaptive schemas as they relate to the development of

psychopathology, and of the ED and depression literature particularly as they relate to childhood

maltreatment is included.

Childhood Emotional Maltreatment

Initial research on the enduring effects of child maltreatment has focused almost

exclusively on outcomes associated with child sexual and physical abuse. However, recent

research has responded to the call for studies examining the impact of other forms of abuse,

particularly emotional maltreatment, a term which has been referred to synonymously with labels

such as emotional abuse and/or neglect, psychological battering, verbal abuse, and most

frequently psychological abuse (Glaser, 2002; Hart, Binggeli, & Brassard, 1997; Hart &

Brassard, 1987; Kent & Waller, 2000; O’Hagan, 1995). Although the use of variable

terminology has caused some to argue that using the terms interchangeably may increase

measurement error by falsely presuming that we are examining the same construct (O’Hagan,

1995), deliberate efforts to define study variables appears to have mostly negated this dilemma.

Furthermore, increased reliance on certain measures or “gold standards,” including the

Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998) and the Lifetime Experiences

Questionnaire (LEQ; Rose, Abramson & Kaupie, 2000) has allowed for increased

generalizability across studies.

While an extensive discussion of the different ways in which emotional maltreatment is

defined within the child abuse literature as well across disciplines is beyond the focus of the

current review, some of the more frequently used definitions are worth mentioning. Emotional

abuse has been described as “soul murder” (Garbarino, Guttman, & Seely, 1986), consisting of

4

recurrent parental attacks that serve to devalue, reject, ignore, and undermine a child’s

development and emerging identity. More recent conceptualizations have suggested that

emotional abuse exists on a continuum, highlighting the repetitive nature of the emotional pain

inflicted on the child (e.g. despair, distress, fear, humiliation, dehumanization) as a crucial

component of the definition (Kent & Waller, 2000; O’Hagan, 1995). For the purposes of this

study, emotional maltreatment encompassed both emotional abuse and emotional neglect.

Emotional abuse is defined as “verbal assaults on a child’s sense of worth and well-being, or any

humiliating, demeaning, or threatening behavior directed toward a child by an adult or older

person” (CTQ; Bernstein & Fink, 1998, p.2). Given that this definition refers to acts of

commission or “active” abuse without accounting for emotional damage resulting from the

absence of parental support and responsiveness (i.e., more “passive” maltreatment), this study

also considered the effects of what Bernstein and Fink (1998) refer to as emotional neglect.

Defined as “failure of caretakers to provide a child’s basic psychological and emotional needs,

including love, encouragement, and belonging, and support” (CTQ; Bernstein & Fink, 1998,

p.3), emotional neglect has received increasing attention among researchers (Yates & Wekerle,

2009). Similarly the LEQ (Rose, Abramson & Kaupie, 2000) considers belittling, ridicule,

humiliation, rejection, extortion, and terrorizing as evidence of emotional abuse, while emotional

neglect is conceptualized as instances where the child is ignored, parentified, isolated, or when

caregivers withhold praise, affection, or are psychologically unavailable to the child.

Although studies investigating the enduring impact of emotional maltreatment lag behind

research on childhood sexual and physical abuse (Behl, Conyngham, & May, 2003), compelling

evidence suggests that emotional maltreatment is associated with negative outcomes in early

childhood (Binggeli, Hart, Brassard, & Karlson, 2005; Egeland, 2009), as well as later childhood

5

and adolescence (Hart, Binggeli, & Brassard, 1998; Lumley & Harkness, 2007; Shaffer, Yates,

& Egeland, 2009). In addition to the impact of emotional maltreatment on child and adolescent

development, recent research has confirmed the enduring effect of emotional maltreatment.

Specifically, a history of emotional maltreatment has been associated with a range of adult

psychological difficulties including increased depression (Gibb et al., 2001; Hankin, 2005;

Maciejewski & Mazure, 2006), anxiety (Spertus, Yehuda, Halligan, & Seremetis, 2003),

posttraumatic stress (Burns, Harding, & Jackson, 2010; Spertus et al, 2003), loneliness and social

isolation (Loos & Alexander, 1997), low self-esteem (Briere & Runtz, 1990; Finzi-Dottan &

Karu, 2006; Mullen et al., 1995), substance use severity (Hyman, Garcia, Sinha; 2006), eating

psychopathology (Gerke, Mazzeo, Kliewer, 2006; Mazzeo & Espelage, 2002; Kent & Waller,

2000), and personality disorders (Carr & Francis, 2009; Grilo & Masheb, 2002) as well as

physical health outcomes such as lower self-rated health (Irving & Ferraro, 2006), increased

healthcare utilization (Spertus et al., 2003), and subsequent victimization (Messman-Moore &

Brown, 2004; Rich, Gidycz, Warkentin, Loh,, & Weiland, 2005).

Although there are certainly benefits of examining the impact of multiple forms of

maltreatment simultaneously, understanding the association between specific forms of abuse and

the etiology and development of specific psychological disorders is warranted, particularly as it

relates to prevention and treatment. This may be particularly relevant for understanding the

sequelae of emotional maltreatment given a considerable portion of adults engaging in various

maladaptive behaviors endorse experiences of emotional maltreatment at the exclusion of other

forms of abuse. For example, in a recent study investigating the association of child abuse and

ED symptomatology, 54% of women who endorsed a history of emotional abuse denied a history

of sexual or physical abuse (Messman-Moore & Garrigus, 2007). Similarly, studies investigating

6

the impact of adult retrospective reports of emotional maltreatment suggest that this form of

abuse is alarmingly common, with prevalence rates ranging from 5.6% to 34.8%, depending on

the sample (Messman-Moore & Garrigus, 2007; Mullen, Martin, Anderson, Romans, &

Heribson, 1996; Spertus et al., 2003). In community samples, rates of emotional maltreatment

were approximately 14% for women and 10% for men (Scher, Forde, McQuaid, & Stein, 2004),

while reported prevalence rates among college women from two recent studies ranged from

12.1% to 24.6% (Burns, Jackson, & Harding, 2010; Messman-Moore & Garrigus). A recent

review of empirical studies that exclusively relied on the CTQ to measure emotional abuse and

neglect reported rates as high as 42.2% for emotional abuse and 44.7% (when using a minimum

cut-off of 9 for the emotional abuse subscale and 10 for the emotional neglect subscale) in

community samples (which included several undergraduate samples) (Baker & Maiorino, 2010).

Moreover, rates of emotional maltreatment were significantly higher in the clinical samples than

in the community samples (Baker & Maiorino, 2010). Further evidence of the pervasiveness of

emotional abuse is supported by findings from a study by Mazzeo and Espelage (2002) which

indicated that, in both the validation and cross-validation samples, emotional abuse was the most

frequently endorsed maltreatment experience with nearly two thirds of both samples reporting at

least one item on the CTQ emotional abuse and neglect subscale. Finally, as previously

discussed, our theoretical and empirical understanding of the influence of emotional

maltreatment on the development of maladaptive coping behavior and subsequent psychological

distress is less understood in comparison to sexual and physical abuse.

7

Emotional Maltreatment and Depression

Empirical research investigating the enduring impact of emotional maltreatment has

certainly dispelled the myth that this is an innocuous form of abuse unworthy of attention.

Following the initial wave of research that related emotional maltreatment to a variety of

problematic adult behaviors, several researchers have theorized that emotional maltreatment may

be more strongly associated with depressive symptomatology than sexual and physical abuse

(Gibb et al., 2001; Hankin, 2005; Liu et al., 2009). For example, emotional maltreatment has

been linked to increased rates of depression among college students (O’Dougherty Wright,

Crawford, & Del Castillo, 2009), in a community sample of over 9,000 adult HMO members

(Chapman et al., 2004), as well as in a clinical sample (Kaplan & Klinetob, 2000). Notably,

significantly greater levels of CEA have also been shown to distinguish patients with treatment-

resistant depression and chronic PTSD from patients with treatment responsive depression

(Kaplan & Klinetob, 2000).

According to Rose and Abramson (1992), emotional maltreatment, unlike other forms of

abuse, is characterized by repetitive verbal statements regarding a child’s self-worth and abilities.

These insults often become internalized, subsequently serving as the foundation for the child’s

negative cognitions that contribute to the onset of depression. Although there is evidence that

CSA and CPA are also risk factors for adult depression, it has been hypothesized that the

cognitive schemas that may result from these forms of abuse are less likely to be structured by

explicit, destructive messages directly supplied by the abuser (Rose & Abramson, 1992).

Empirical support for Rose and Abramson’s (1992) theory comes from a study where

participants with high or low cognitive risk for depression (based on the presence or absence of a

negative cognitive style) were followed longitudinally for 2.5 years. Results suggested that

8

childhood emotional, as opposed to physical or sexual, abuse was associated with increased

levels of hopelessness and nonendogenous major depression (NE-MD) as well as hopelessness

depression (HD) at prospective follow-up. Participants who were categorized as evidencing a

high cognitive risk for depression also reported more childhood emotional maltreatment than

individuals with low cognitive risk for depression. Furthermore, results indicated that cognitive

risk fully mediated the relationship between CEA and NE-MD and the relation between CEA

and HD (Gibb et al., 2001).

A recent prospective study explored whether experiences of current emotional

maltreatment predicted the emergence of depression, including major (MD), minor (MiD), and

the subtype of hopelessness depression (HD) in undergraduates (Liu et al., 2009). Findings

revealed that greater emotional maltreatment predicted earlier onset of MD, MiD, an HD

episodes. Furthermore, the authors examined emotional maltreatment perpetrated by peers and

authority figures separately and found that both types predicted shorter time to onset of HD

episodes specifically. In addition to being the first study to provide evidence that current

emotional maltreatment predicts the onset of clinically significant depressive episodes using a

fully prospective design, the authors highlight the importance of targeting experiences of

emotional maltreatment and its appraisal in therapeutic intervention (Liu et al., 2009).

Depression and Eating Disorder Symptomatology

Extensive comorbidity exists between eating disorders (EDs) and depression as

individuals with an ED often report a current or lifetime history of depression (Herzog, Keller,

Sacks, Yeh, & Lavori, 1992; Polivy & Herman, 2002; Wilksch & Wade, 2004). Lifetime

prevalence rates of major depression in ED diagnoses range from 36% to 73% (Halmi, 1995;

9

Hudson, Pope, Jonas, & Yurgelun-Todd, 1983) for bulimia nervosa (BN) with rates as high as

86% for anorexia nervosa (AN) in one study (Rastam, 1992). Increased rates of depression have

also been found in subclinical levels of ED (Cowen, Anderson, & Fairburn, 1992).

Although there are a number of explanations for the link between EDs and depression,

one potential pathway that has received recent empirical support involves brain serotonin levels.

Decreased serotonin levels have been implicated in depression and recent studies suggest that

individuals with bulimia may have lower serotonin levels than normal controls. Although

carbohydrate dense binges tend to alleviate this deficit, the effects are temporary and may

reinforce similar behavior in an effort to experience the “high” associated with increased

serotonin levels (Agras & Apple, 2008). Therefore one function of binge-eating behavior, a

component of the binge-purge subtype of AN, as well as BN and Binge-Eating Disorder (BED),

may be to initially distract from depressive symptoms. Notably, women who are obese as well as

of normal weight report significantly more symptoms of depression than those who do not

endorse binge-eating behavior (Marcus et al., 1990; Webber, 1994). Unfortunately, the very

symptoms that bingeing distracts from are often exacerbated with each subsequent binge as ED

sufferers report feeling powerless against both the ED behavior and the recurrence of negative

mood states (Agras & Apple, 2008, Fairburn, 2008). As a result of the theoretical and empirical

link between depression and disordered eating behaviors, current cognitive models used to

explain this association, including Fairburn’s Cognitive Behavioral Therapy (CBT) model for

bulimia and binge eating (Agras & Apple, 2008; Fairburn, 2008; Fairburn, Marcus, & Wilson,

1993) include negative affect and low self-esteem (two hallmark symptoms of Major

Depression), in addition to loss of control, dieting, and weight and shape concerns as factors

believed to maintain binge eating and purging behavior.

10

Conversely, it is equally important to acknowledge that the relationship between EDs and

depression observed throughout the literature may be the result of common psychological

correlates of both disorders. For example, in a recent study designed to investigate the comorbid

relationship between EDs and unipolar depression, findings revealed that in a regression model

explaining 72.2% of the variance in ED behaviors, depression scores contributed a minimal 1%

of the variance after controlling for self-esteem, social comparison, and body dissatisfaction

(Green et al., 2009). However, before discussing theoretical models linking a history of

emotional maltreatment with the development of EDs, a brief review of the ED literature as it

relates to child maltreatment is necessary.

Child Maltreatment & Eating Disorder Symptomatology

Child abuse was first considered a distal risk factor for eating psychopathology as a result

of research examining the impact of childhood sexual abuse (CSA) specifically. Results of a

recent metal-analysis investigating prevalence rates of sexual abuse among ED samples

suggested that individuals with BN endorsed higher rates of sexual abuse than those without

bulimia (Smolak & Murnen, 2002). Gentile and researchers (2007) included childhood physical

abuse (CPA) in their investigation and found that among ethnically diverse college students, both

physical and sexual abuse independently contributed to increased risk for EDs among women.

Although estimates of prevalence rates of CSA victims with EDs are limited, Johnson and

researchers (2002) reported that 6.6% (or 52 youths) met diagnostic criteria for an ED in their

community-based prospective longitudinal study comprised of 780 mothers and their offspring

with and without an abuse history. Although studies examining this link are limited, initial

research provides preliminary evidence for an association between abuse and EDs, with some

11

researchers proposing that CSA, in particular, may serve as a non-specific risk factor for the

development of eating psychopathology (Smolak & Murnen, 2002).

More recent research has begun to consider the influence of emotional maltreatment in

ED research, with initial findings suggesting that emotional maltreatment may be more strongly

associated with ED behavior than other forms of abuse (Gerke, Mazzeo, Kliewer, 2006; Mazzeo

& Espelage, 2002; Kent & Waller, 2000). For example, Humphrey, Apple, and Kirschenbaum

(1986) found that bulimic and anorexic women report their families as being more belittling and

attacking than non-eating disordered controls. Although this study did not include a specific

measure of emotional maltreatment, a “belittling and attacking” family environment may be

conceptualized as part of the continuum of emotional maltreatment (Kent & Waller, 2000).

In the mid-1990s in response to increased attention to the sequelae of emotional

maltreatment within the extant literature, ED researchers began assessing emotional

maltreatment more directly. Results indicated higher rates of emotional (termed psychological),

physical, and multiple abuse among individuals with bulimia compared to the control group

(Rorty, Yager, & Rossotto, 1994). In only the second study to examine the relationship between

ED symptoms and a range of child abuse experiences including childhood emotional abuse

(CEA), Kent and colleagues (1999) reported that although all forms of child abuse were related

to dysfunctional eating attitudes, CEA emerged as the only form of childhood trauma that

predicted unhealthy adult eating attitudes once covariance between the different forms of abuse

was controlled. Furthermore, results indicated that the association between CEA and unhealthy

adult eating attitudes was perfectly mediated by the women’s level of anxiety and dissociation

(Kent, Waller, & Dagnan, 1999).

12

Shortly thereafter, a review of empirical support for the relationship between CEA and

eating psychopathology, in addition to a proposed theoretical model outlining the potential role

of emotional abuse as a risk factor in the development of eating psychopathology, was published

by the same authors (Kent & Waller, 2000). The model identified several moderating variables,

including age of onset of abuse and gender of the perpetrator, in addition to proposing cognitive-

affective processes (e.g. dissociation, shame, anxiety, and self-esteem) that might act as

mediators. Notably, the author clearly conceptualized CEA as a risk factor for the development

of more general symptomatology, common to both bulimia and anorexia, such as low self-

esteem, body dissatisfaction, and restrictive eating (Briere & Runtz, 1990, Gross & Keller, 1992,

Kent & Waller, 2000), rather than suggesting that emotional maltreatment was uniquely related

to one particular eating disorder. This represented a change from previous literature linking CSA

and CPA to EDs, suggesting that the authors conceptualized the impact of emotional abuse as

having a more generalized impact on disordered eating behavior. Certainly, past research

provides support for this notion, as CSA and CPA appear to better predict bulimic rather than

restrictive symptomatology (e.g. Bushnell, Wells, & Oakley-Browne, 1992, Schmidt, Slone,

Tiller, & Treasure, 1993).

Mazzeo and Espelage (2002) attempted to expand our understanding of the relationship

between emotional abuse and disordered eating by using structural equation modeling (SEM) to

test alexithymia and depression as mediating variables. Results revealed that CPA, CEA, and

physical and emotional neglect were not directly related to disordered eating. Rather, alexithymia

and depression emerged as significant mediators between physical and emotional abuse history

and disordered eating. Although previous research did not find that depression mediated the

relationship between emotional abuse and disordered eating (Kent, Waller, & Dagnan, 1999), it

13

was hypothesized that this may be a result of different statistical analyses, since multiple

regression, unlike SEM, does not identify measurement problems that may influence results

(Mazzeo & Espelage, 2002).

In response to evidence from cross-sectional research linking emotional maltreatment and

eating psychopathology, Johnson and colleagues (2002) conducted a community-based

prospective longitudinal study to examine whether child maltreatment predicts eating and

weight-related problems during adolescence and early adulthood (Johnson, Cohen, Kasen, &

Brook, 2002). Results indicated that a range of childhood adversities were related to increased

risk for disordered eating and weight problems during adolescence and adulthood, even after

statistically controlling for the effects of several confounding variables (e.g. age, challenging

childhood temperaments, childhood eating problems, parental psychopathology, and co-

occurring childhood adversities). Furthermore findings suggest that maladaptive paternal

behavior (e.g. low paternal affection, communication, and time spent with child), a construct that

may be subsumed under the more passive forms of emotional abuse and neglect, was uniquely

associated with risk for eating disorders in offspring (Johnson et al., 2002).

While Johnson and researchers (2002) provide additional support for the relationship

between CEA and disordered eating by examining the relationship in a community sample, Grilo

and colleagues (2005) sought to investigate this relationship in more clinically relevant

population. By examining rates of self-reported childhood maltreatment in extremely obese

bariatric surgery candidates, analyses indicated that CEA was uniquely associated with increased

body dissatisfaction, while emotional abuse and neglect were both related to stronger eating

concerns, elevated depression, and decreased self-esteem after Bonferonni corrections (Grilo,

Masheb, Brody, Toth, Burke-Martindale, & Rothschild, 2005). Although results indicated that

14

child maltreatment in general was not significantly associated with current BMI, binge-eating, or

eating disorder features, bariatric surgery patients reported rates of child maltreatment two to

three times more than those reported in normative samples. In a more recent study from the same

lab, individuals with binge eating disorder (BED) and night eating syndrome (NES) endorsed

increased rates of emotional abuse, but not sexual or physical abuse, when compared to

overweight individuals without an eating disorder diagnosis (Allison, Grilo, Masheb, &

Stunkard, 2007). Again, BMI was not found to relate to abuse, but results provided further

support for the unique association between emotional abuse and depression.

A more recent study continued to investigate these relationships in a sample of treatment

seeking overweight adults who met DSM-IV criteria for Binge Eating Disorder (BED).

Researchers examined the mediating role of self-criticism in the relation between childhood

maltreatment and both depressive symptoms and body dissatisfaction (a variable suspected to

lead to a variety of maladaptive ED behaviors). Path analyses demonstrated that self-criticism

fully mediated the relationship between emotional abuse and depressive symptoms and body

dissatisfaction. The authors highlighted that emotional abuse, unlike sexual abuse, was

associated with greater depressive affect in BED patients providing further support for the

potentially unique association between emotional abuse and depression (Dunkley, Masheb, &

Grilo, 2010).

Impact of Mediating Variables

Although the above studies provide support for the relationship between emotional

maltreatment and eating psychopathology, previous theoretical work in combination with recent

empirical findings propose that this link is not direct (Fischer & Hartzell, 2009; Hund &

15

Espelage, 2006; Mazzeo & Espelage, 2002; Kent & Waller, 2000). Instead, there are likely a

number of psychological and physiological mediators that more fully explain the distal

relationship between emotional maltreatment and the development of ED symptomatology (Kent

& Waller, 2000). Far less research has examined mediators and moderators as they relate to

emotional maltreatment and adult maladjustment (O’Dougherty Wright, Crawford, & Del

Castillo, 2007), let alone examined subsequent eating psychopathology. Two recent studies have

attempted to address this gap in the literature. Hund and Espelage (2006) used structural equation

modeling to test conceptual models relating CEA to disordered eating among undergraduate

females. Results revealed a weak, but significant complex relationship between CEA and

disordered eating that was mediated by alexithymia and general distress (a composite measure of

anxiety and depression) (Hund & Espelage, 2006). In a similar study, Gerke and colleagues

(2006) examined the role of depression and dissociation as possible mediators between

childhood trauma and bulimic symptomatology in a sample of ethnically diverse female

undergraduates. Results indicated that only CEA was correlated with bulimic symptoms and

therefore other forms of trauma were excluded from further analyses. Furthermore, dissociation

was no longer associated with CEA after controlling for depression. Consequently, the final

model indicated that depression mediated the relationship between CEA and bulimic symptoms

(Gerke, Mazzeo, & Kliewer, 2006).

Efforts to increase both our theoretical and empirical understanding of how emotional

maltreatment results in ED behavior has led researchers to propose a number of potential

mechanisms that may impact this relationship. For example, Fischer and Hartzell (2008)

discussed several hypothesized pathways from CEA to the development of subsequent ED

disturbances, including the mediating role of poor interoceptive awareness, dieting, and emotion

16

regulation. Bruch (1973) first identified poor interoceptive awareness, or difficulties with hunger

and satiety cues, resulting from an environment in which a child’s needs are not sufficiently

addressed, as a potential risk factor for disordered eating. Dieting has also been proposed as a

factor that increases binge eating behavior, although the specific way in which restrictive eating

leads to increased binge behavior is still being debated (Fairburn, Marcus, & Wilson, 1993).

Similarly, the way in which emotional abuse may lead to dieting has not been studied, although

low self-esteem (potentially resulting from repetitive emotionally abusive statements) may be

one pathway in which emotional maltreatment initiates attempts to modify weight and shape and

subsequent binge eating (Fischer & Hartzell, 2008).

Finally, recent research has examined what has been referred to as the emotion regulation

hypothesis of binge behavior. Specifically, Heatherton and Baumeister (1991) speculate that the

function of binge eating is to distract from an abstract stimulus (negative thoughts about self;

painful emotions) with a concrete stimulus (food). As previously discussed, binge eating as an

attempt to regulate negative affect has received empirical support within the literature (Fischer,

Smith, Annus, & Hendricks, 2007; Kell, Klump, & Fulkerson, 1997; Stice, 2002) and may be

extended to incorporate emotional maltreatment in that CEA may serve as a risk factor for low

self-esteem. Poor self-esteem may elicit negative affect, which in turn may initiate disordered

eating behavior as an attempt to cope with overwhelming affective states.

In addition to the above mediators, researchers have also considered the role of negative

cognitions or core beliefs in understanding and treating EDs, particularly bulimia (Cooper, 1997;

Fairburn, 1997; Kennedy, 1997; Waller, Ohanian, Meyer, Osman, 2000). Given that emotional

maltreatment encompasses both active and passive attempts to undermine a child’s self-efficacy,

it seems plausible that a child may internalize their abuse experience fostering negative

17

cognitions. While ED researchers have investigated disturbances in cognitions regarding eating,

weight, and shape among women endorsing ED behavior, researchers agree that eating related

cognitions are not sufficient explanatory constructs (Fairburn, Cooper, & Shafran, 2003;

Kennerley, 1996; Waller, Kennerley, & Ohanian, 2007; Waller et al., 2000). Therefore, core

beliefs and subsequent affective experiences (e.g., early maladaptive schemas) that are more

generalized, pervasive, and deeply seated about the self and others may explain more variance in

the development of ED behavior as an effort to manage distress associated with negative

intrusive thoughts.

Early Maladaptive Schemas

Definition

In an effort to further articulate the potential mediating role of core beliefs in the

development of eating disturbances among individuals with a history of emotional maltreatment,

it is necessary to discuss the construct of early maladaptive schemas (EMS) as conceptualized by

Young (see Young, 1994, 1999; Young, Klosko, & Weishar, 2003 ), in further detail. Young and

colleagues developed schema therapy in response to clinical observations that patients with

longstanding difficulties and what he described as “chronic characterological problems” were not

responding to traditional CBT. Dating back to ancient Greek philosophy, the term “schema”

refers to a structure, framework, or outline. Young has expanded the traditional definition to

describe “a broad pervasive theme or pattern comprised of memories, emotions, cognitions, and

bodily sensations” (Young, 1994, 1999; Young, Klosko, & Weishaar, 2003). Young further

explained that schemas incorporate cognitions and emotions of an intrapersonal and

interpersonal nature, that they originate in early childhood or adolescence, and that often they

18

become increasingly elaborate with time and experience. Although positive schemas certainly

exist, Young was most interested in the dysfunctional, self-defeating, and impairing schemas that

he suspected underlie psychopathology and subsequently labeled them early maladaptive

schemas (EMS). Furthermore, EMS are distinguished from the maladaptive behaviors that often

result as a consequence of the distress associated with schema activation. In other words,

behaviors such as substance abuse, inappropriate sexual behavior, and disordered eating are

driven by schemas, but are not part of the schema itself (Young, Klosko, & Weishaar, 2003).

Young suggests that schemas are entrenched, fighting for survival at significant cost to the

individual. In fact, he surmises that individuals are often drawn to situations or people that

trigger their schemas in part due to human nature’s tendency to favor familiarity over change.

Moreover, the more severe or debilitating the schema, the greater the frequency of activation and

the more likely the individual will be to enact various, often maladaptive, coping behaviors.

In an effort to measure the impact of EMS, Young developed the Young Schema

Questionnaire (YSQ: Long Form) comprised of 18 theoretically derived schemas. More recently,

a shorter version yielding 15 schemas has been created (YSQ-SF; Young, 1994) and will be used

in the current study to measure five proposed schema domains (See Table 1). The first domain,

referred to as Disconnection & Rejection, assesses expectations that individual needs for

security, stability, emotional validation, and respect will not be reliably met and includes the

following five schemas: Abandonment/Instability, Mistrust/Abuse, Emotional Deprivation,

Defectiveness/Shame, and Social Isolation/Alienation. Individuals with elevations in this domain

tend to experience coldness, rejection, loneliness, and invalidation in their family of origin, with

more extreme cases reporting abuse experiences. The second domain labeled Impaired Autonomy

& Performance, characterizes people whose expectations about their self and others interferes

19

with their ability to function independently or successfully. This domain includes four schemas:

Dependence/Incompetence, Vulnerability to Harm or Illness, Enmeshment/Undeveloped Self,

and Failure. The third domain measures deficits in internal and external boundary setting,

including inability to honor responsibility to others, in addition to difficulty achieving long-term

goals and is labeled Impaired Limits. The Impaired Limits domain includes two schemas:

Entitlement/Grandiosity and Insufficient Self-Control/Self-Discipline. The fourth domain referred

to as Other-Directedness, includes two schemas: Subjugation and Self-Sacrifice. These schemas

measure an individual’s tendency to focus excessively on the needs and approval of others at the

expense of their own desires. The final schema domain is labeled Overvigilance & Inhibition and

is also comprised of two schemas: Emotional Inhibition and Unrelenting

Standards/Hypercriticalness. Individuals with schema elevations in this domain reportedly

restrict emotion expression and related communication in an effort to avoid disapproval of others

or overwhelming feelings of shame. Additionally, individuals endorse exaggerated expectations

for themselves across a wide range of areas (Young, Klosko, & Weishaar, 2003).

Childhood Maltreatment & Early Maladaptive Schemas

Young proposes that EMS originate primarily from toxic childhood environments,

specifically the child’s nuclear family, although he suggests that they can result from negative

peer or extra-familial relationships. The latter negative experiences, however, are posited to be

less powerful especially if the family environment is a source of strength (Young, Klosko, &

Weishaar, 2003). Young further describes four types of early life experiences that facilitate

schema development. The first is referred to as toxic frustration of needs and results when the

child experiences deficits in basic needs including positive emotions and secure attachment.

20

EMS such as Emotional Deprivation or Abandonment often develop. The second environment is

characterized by traumatic experiences, including exposure to abuse, neglect, or other adverse

child experiences (e.g., loss of a parent or caregiver, physical injury resulting from motor-vehicle

accident or other environmental disaster). Resulting schemas include Mistrust/Abuse,

Defectiveness/Shame, or Vulnerability to Harm. In the third type of family environment, a child

is overindulged and develops schemas such as Dependence/Incompetence or

Entitlement/Grandiosity as a consequence of not learning to appropriately separate from the

familial environment and develop an autonomous self. The fourth environment results when a

child selectively identifies with significant others and internalizes that parent or caregiver’s

thoughts, feelings, and behaviors as their own. The specific schemas that arise from this

environment depend on the type of experiences the child internalizes.

Recent studies have provided empirical support for Young’s primarily theory driven early

environmental typology. EMS have shown associations with childhood adversity and subsequent

maladjustment in adolescents (Lumley & Harkness, 2007) and adults (Harris & Curtin, 2002;

McGinn, Cukor, & Sanderson, 2005; O’Dougherty Wright, Crawford, & Del Castillo, 2009;

Schmidt, Joiner, Young, & Telch, 1995). For example, the EMS of Defectiveness, Insufficient

Self-Control, Incompetence, and Vulnerability were found to partially mediate the association

between maladaptive parenting styles (e.g., low parental care and high parental overprotection)

as measured by the Parental Bonding Instrument (PBI; Parker, Tupling, & Brown, 1979) and

depression severity (Harris & Curtin, 2002). Recently, a significant association was found

between child maltreatment, with the exclusion of childhood physical neglect as measured by the

CTQ, and the Disconnection & Rejection schema domain (apart from the Abandonment

subscale). Contrary to expectations and previous research linking emotional maltreatment to

21

symptoms of Avoidant Personality Disorder (AVPD), the current study did not find support for a

potential mediating pathway from childhood maltreatment and AVPD through the Disconnection

& Rejection domain due to the non significant pathways between child maltreatment and AVPD

as well as between the schema domain and AVPD (Carr & Francis, 2010). EMS have also been

found to distinguish between adolescent perpetrators of sexual abuse and those without a

perpetration history. Richardson (2005) found that the Emotional Inhibition, Social

Isolation/Alienation, and Mistrust/Abuse schemas were most elevated among adolescent

perpetrators and reliably distinguished between adolescent perpetrators with and without a CSA

history. Furthermore, among perpetrators, schema scores were found to differentiate between

adolescents who victimized children versus those who reported acts against peer-aged or adult

females (Richardson, 2005).

In another study of adolescents, Lumley and Harkness (2007) examined the role of

specific EMS in predicting negative mood symptoms among participants with a maltreatment

history. More specifically, they predicted that EMS with themes of danger, (e.g., Mistrust/Abuse

and Vulnerability), which they distinguished based on the content of schemas, would predict

anxious symptomatology among physically maltreated adolescents. Conversely, it was

hypothesized that schemas with themes of loss/worthlessness (e.g., Emotional Deprivation,

Dependency, Defectiveness, Failure, and Social Isolation) would predict anhedonic depression

symptoms among adolescents exposed to emotional maltreatment. Results from the first study to

empirically examine the specificity of Young’s EMS reported mixed support for their

hypotheses. More specifically, the authors did not find specificity in the relationship between

emotional maltreatment and anhedonic depressive symptoms, nor between physical abuse and

anxiety. Instead, both forms of maltreatment predicted anxious and anhedonic symptoms.

22

However, results provided support for schema specificity in predicting subsequent symptoms in

that danger schemas mediated the relationship between general child maltreatment and anxious

symptoms, while loss/worthlessness schemas preferentially mediated the association between

maltreatment and anhedonic symptoms. Notably, specificity emerged exclusively in the

meditational analyses (Lumley & Harkness, 2007).

In addition to providing additional support for Beck’s content- specificity hypothesis

(Beck, 1976), Lumley and Harkness (2007) are some of the first researchers to examine

emotional maltreatment in relation to EMS. Although results did not suggest that emotional

maltreatment preferentially predicted certain schema elevations, the finding that emotional

maltreatment was significantly related to schema elevations provides support for including

emotionally abusive experiences in Young’s conceptualization of the toxic environment that

results in schema development. This is an important development because much of the research

previously relating abuse experiences to schema development and subsequent pathology has

been done exclusively with survivors of sexual and physical abuse.

Early Maladaptive Schemas & Psychopathology

Recent evidence has provided support for Young’s theory that psychological disorders

can be explained by EMS and the problematic ways in which individuals learn to manage them.

Using both long and short versions of the YSQ, results suggest EMS predict adolescent and adult

depression (Harris & Curtin, 2002; Lumley & Harkness, 2007; O’Dougherty Wright, Crawford,

& Del Castillo, 2009; Wang, Halvorsen, Eisemann, & Waterloo, 2010), anxiety (O’Dougherty

Wright, Crawford, & Del Castillo, 2009), social phobia (Pinto-Gouveia, Castilho, Galhardo, &

Cunha, 2006), PTSD (Cockran, Drummond, & Lee, 2010; Price, 2007), ED symptomatology

23

(Dingemans, Spinhoven, & van Furth, 2006; Leung, Waller, & Glyn, 1999; Unoka, Tolgyes, &

Czobor, 2007; Unoka, Tolgyes, Czobor, & Simon, 2010; Waller, Ohanian, Meyer, & Osman,

1999; Waller et al., 2001) personality disorders and subtypes (Carr & Francis, 2010; Petrocelli,

Glaser, Calhoun, & Campbell, 2001; Thimm, 2010), self-harm behaviors (Castille et al., 2007),

attachment difficulties (Mason, Platts, & Tyson, 2005), interpersonal conflict (Messman-Moore

& Coates, 2007) and general psychological (Schmidt & Joiner, 2004) and occupational distress

(Bamber & McMahon, 2008).

In addition to evidence that individuals endorsing a variety of psychological symptoms,

including those who meet full diagnostic criteria for clinical disorders, evidence elevated schema

profiles when compared to normal controls (Carine, 1997), recent studies suggest that particular

schemas may be more predictive of specific symptom presentations (Lumley & Harkness, 2007;

Messman-Moore & Coates, 2007; O’Dougherty Wright, Crawford, & Del Castillo, 2009; Waller

et al., 2000). Although evidence supporting the latter conclusion is preliminary, the findings lend

support to Beck’s content-specificity hypothesis, which indicates that psychological disorders

and states ought to be “differentiated by the content of their cognitive associates” (Beck, 1976).

For example, patients with social phobia evidenced higher levels of EMS in the

Disconnection/Rejection domain compared to patients with other anxiety disorder diagnoses

(Pinto-Gouveia et al., 2006). Further analyses specified that EMS of Mistrust/Abuse, Entitlement,

Emotional Deprivation, Unrelenting Standards, and Social Undesirability/Defectiveness (the

Social Isolation and Defectiveness schemas formed one factor in this study) contributed the most

variance in reported anxiety as it related to social situations and fear of negative evaluation

(Pinto-Gouveia et al., 2006). Lastly, the EMS of Mistrust/Abuse, Emotional Deprivation, Social

Isolation/Alienation, and Insufficient Self-Control/Self-Discipline reliably differentiated

24

individuals engaging in self-harm from those not engaging in self-harm behavior (Castille et al.,

2007). Schema elevations were also able to distinguish between repetitive self-harm and

individuals reporting only one episode of self-harm.

Early Maladaptive Schemas and Depression

As previously described, Lumley and Harkness (2007) found that schemas reflecting

loss/worthlessness (i.e., Emotional Deprivation, Dependency, Defectiveness, Failure, and Social

Isolation) preferentially mediated the association between maltreatment and depressive

symptoms (referred to as anhedonic symptoms) among a sample of 76 depressed adolescent boys

and girls. Similarly, Defectiveness/Shame and Failure (Incompetence/Inferiority) schemas, in

addition to Vulnerability and Insufficient Self-Control/Self-Discipline, were found to partially

mediate the relationship between perceptions of parenting behavior and depressive symptoms

among undergraduates (Harris & Curtin, 2002). In a confirmatory factor analytic study designed

to test the structure of the YSQ domains, the Disconnection & Rejection and Impaired Autonomy

schema domains explained up to 53% of the variance in depression severity in a sample of

clinically depressed (CD), previously depressed (PD), and never depressed (ND) individuals

(Hoffart et al., 2005). In a similar design, CD and PD individuals differed significantly on EMS

profiles compared with ND (Halvorsen et al., 2009). More specifically, YSQ domain scales of

Disconnection & Rejection and Impaired Autonomy emerged as significant predictors of

depression severity replicating previous findings (e.g., Hoffart et al., 2005), in addition to the

Impaired Limits (i.e., Entitlement and Insufficient Self-Control) and Restricted Self-Expression

(Emotional Inhibition, Self-Sacrifice, and Unrelenting Standards). Notably, the Insufficient Self-

25

Control schema was also found to significantly relate to depression in a previous study (e.g.,

Harris & Curtin, 2002).

More recently, efforts to examine the stability of early maladaptive schemas

characterizing individuals vulnerable to depression suggested moderate significant relative

stability for the Disconnection & Rejection and Impaired Limits schema domains, even after

controlling for depression severity in a nine-year follow-up study of depressed patients. Findings

not only highlight the stability of the EMS over time, but underscore the predictive utility of

EMS scales as vulnerability markers for depression (Wang et al., 2010).

In one of the few studies to examine the relationship between emotional maltreatment,

EMS, and depression, hierarchical regression analyses revealed that after controlling for the

effects of gender, income, parental alcohol, and other child abuse experiences, both emotional

abuse and neglect were associated with symptoms of anxiety and depression. Notably, this

association was partially mediated by schemas of Vulnerability to Harm, Shame, and Self-

Sacrifice (O’Dougherty Wright, Crawford, & Del Castillo, 2009).

Early Maladaptive Schemas and Eating Psychopathology

Although researchers have long considered the role of negative cognitions (Kennerley,

1997) in the understanding and treating ED behaviors, empirical work examining the role of

cognitions has been relatively limited. For example, Dobmeyer and Stein (2003) investigated the

role of maladaptive cognitions, in addition to drive for thinness, depressed mood, and low self-

esteem/self-efficacy, in the development of ED symptoms in a 4-year prospective study of

female undergraduates. Findings suggested that initial maladaptive cognitions and drive for

thinness scores were more predictive of later eating pathology than the other factors.

26

More recently ED researchers have begun to investigate more entrenched core beliefs,

that are not related to food, weight, or shape, using Young’s measure of EMS. In the first study

to investigate the relation of EMS to ED behaviors, the authors reported that both anorexic and

bulimic women endorsed significantly higher levels of EMS than control participants. Moreover,

results revealed that the ED groups differed on only one schema, Entitlement, with restrictive

anorexics scoring significantly lower than the bulimic women on this scale (Leung, Waller, &

Thomas, 1999). In another study, examining EMS among women reporting symptoms of

bulimia, results indicated that three schemas (Defectiveness/Shame, Insufficient Self-Control, and

Failure) differentiated women endorsing a history of bulimic behaviors from those without

(Waller et al., 2000). Furthermore, there was evidence that among bulimic women, beliefs

regarding emotional restraint, as measured by the Emotional Inhibition EMS, predicted their

severity of binge behavior, whereas their Defectiveness/Shame beliefs predicted severity of

vomiting.

In the most recent study to examine EMS among ED samples, the authors examined

whether three ED subgroups (i.e., restrictive AN, binge-purging AN, and BN) as defined by the

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), exhibited specific

profiles of EMS. Additionally, the relationship between body mass index (BMI) and EMS was

examined in each of the ED subgroups. Principle component factor analysis extracted four EMS

factors, which explained 72% of the variance in eating pathology. Findings indicated that the

three ED subgroups differed on EMS factors, and that elevation on Factor 2 (i.e., Defectiveness,

Failure, Dependence, Enmeshment, Subjugation, Approval Seeking) was related to lower BMI

scores (Unoka, Tolgyes, & Czobor, 2007). Additionally, both subgroups of AN evidenced higher

factor loadings on Factor 3 (i.e., Self-Sacrifice, Unrelenting Standards, and Punitiveness). In

27

other words, individuals with AN often prefer to meet the needs of others at the expense of their

own fulfillment, unlike participants diagnosed with BN. Additionally, the anorexic subgroups

endorsed internalized perfectionist standards and beliefs that they should be punished if they do

not achieve their goals according to their endorsement of high levels of the EMS of Unrelenting

Standards and Punitiveness. These results are in accordance with previously held beliefs that

individuals with AN are more perfectionist and rigid than individuals diagnosed with BN (Keel

et al., 2004; Unoka, Tolgyes, & Czobor, 2007). Moreover, findings are consistent with the notion

that maladaptive cognitions play an integral role in the development and maintenance of ED as

well as support the specification of additional ED subtypes. Finally, further support is provided

for the relation of EMS to ED symptomatology, with preliminary evidence for the association

between specific EMS and particular dysfunctional eating behaviors.

Child Maltreatment, Early Maladaptive Schemas, & Eating Psychopathology

Although no studies to date have investigated how EMS may explain the relationship

between emotional maltreatment and disordered eating behaviors, one study has investigated the

mediating role of schemas among bulimic women endorsing a CSA history (Waller, Meyer,

Ohanian, Elliott, Dickson, & Sellings, 2001). Results of regression analyses supported a model

where bulimics’ EMS levels mediate the relationship between CSA and increased ED behaviors,

with evidence that different schemas serve as mediators depending on the symptom under

investigation, thus providing additional support for schema specificity as it relates to ED

symptoms. For example, Abandonment and Mistrust/Abuse EMS acted as a primary mediator,

with depression serving as a secondary mediator in the model depicting the relation between

CSA and frequency of binge behavior. Conversely, Defectiveness/Shame was the primary

28

mediator, and dissociation and depression served as secondary mediators in the model

associating CSA to frequency of vomiting (Waller et al., 2001).

In the only other study to date to examine the role of EMS as mediators in the

relationship between adversity in childhood and eating psychopathology, researchers

investigated the impact of paternal overprotection (as measured by the PBI) on bulimic

psychopathology. Results revealed that the Mistrust/Abuse and Unrelenting Standards schemas

were the only schemas to significantly predict the presence and severity of bulimic behaviors (as

measured by the BITE; Bulimic Investigatory Test, Edinborough). Further analysis revealed that

only the Mistrust/Abuse schema significantly related to paternal overprotection and therefore the

Unrelenting Standards schema was not included in meditational analyses. Findings indicated that

the Mistrust/Abuse schema served as a partial mediator, reducing the predictive power of the

BITE severity to 4.8% from 11% of the variance when included in the model (Meyer & Waller,

2004).

Summary

Recent theoretical and empirical research has provided preliminary evidence for the

impact of emotional maltreatment on the development and etiology of eating psychopathology,

conceptualized as a psychological disorder, but with potentially devastating physical

consequences, including death (Fischer & Hartzell, 2008; Gerke, Mazzeo, Kliewer, 2006; Kent

& Waller, 2000). Further research is necessary to provide additional support for this relationship,

as well as test potential mediating variables that more fully explain the association between

emotional maltreatment and eating psychopathology. Pervasive and dysfunctional core beliefs

about the self and others that develop secondary to abusive environments, conceptualized by

29

Young as EMS, may explain significant variance in this relationship and are therefore worth

investigating given preliminary evidence relating maltreatment to schema development.

Furthermore, EMS represent a modifiable target for treatment and prevention of EDs. Finally,

examining the impact of depression remains important given theoretical and empirical links

between depression and the other constructs of interest in the current study.

30

Table 1: Description of the Young Schema Questionnaire- Short Form (YSQ-SF; Young 1994)

Domains & Schemas Description of Early Maladaptive Schemas

DISCONNECTION &

REJECTION

Expectation that one’s needs for security, safety, stability, empathy,

acceptance, and respect will not be met in a predictable manner.

Family origin is often cold, invalidating, detached, and potentially

abusive.

1. Abandonment/Instability

2. Mistrust/Abuse

3. Emotional Deprivation

4. Defectiveness/Shame

5. Social Isolation/Alienation

1. The belief that it is only a matter of time until close people

will leave or fail to protect me.

2. The expectation that others will hurt, abuse, humiliate, cheat,

lie, manipulate, or take advantage of me.

3. The belief that others will not provide adequate emotional support or nurturance for me.

4. The belief that one is defective or fundamentally flawed.

5. The belief that one is fundamentally different from others

and does not belong.

IMPAIRED AUTONOMY &

PERFORMANCE

Expectations for the environment and self interfere with perceived

ability to function independently or perform successfully. Family

origin is often enmeshed, overprotective, undermining of child

abilities.

6. Dependence/Incompetence

7. Vulnerability to Harm/Illness

8. Enmeshment/Undeveloped Self

9. Failure

6. The belief that one cannot handle everyday responsibilities

competently, without considerable help from others.

7. The belief that catastrophe is imminent and not preventable.

8. A tendency for one’s identity to fused with significant

others, including excessive emotional involvement.

9. The belief that one is inadequate and unsuccessful and

therefore unable to meet important goals.

IMPAIRED LIMITS Difficulties in personal boundaries, responsibilities to others, or goal

orientation often leads to difficulty respecting others, maintaining

commitments, or achieving realistic goals. Family origin is often

overindulgent, permissive, or lacking discipline or direction. 10. Entitlement/Grandiosity

11. Insufficient Self-Control/ Self-

Discipline

10. The belief that one is better than others and is entitled to

different rights and privileges.

11. The belief that one is unable to control one’s impulses

OTHE -DIRECTEDNESS

Excessive focus on the desires, feelings, and behaviors of others, at

the expense of one’s own needs to gain approval and avoid

interpersonal conflict. Family origin is often based on conditional

acceptance and social status is valued over child’s unique needs.

12. Subjugation

13. Self-Sacrifice

12. The belief that others desires take precedent over one’s own

desires

13. A tendency to be focused on meeting the needs of others

Overvigilance & Inhibition Excessive emphasis on suppressing one’s feelings and impulses or

adhering to rigid, internalized rules. Family origin is often,

perfectionist, demanding, and punitive.

14. Emotional Inhibition

15. Unrelenting Standards

14. The tendency to be emotionally restrictive and reluctance to share emotions.

15. The belief that one should strive to meet unattainable levels

of achievement and perfection.

31

CHAPTER 2

RATIONALE AND HYPOTHESES

The purpose of the current study was to investigate the relationships among emotional

maltreatment, maladaptive schemas, depression, and disordered eating behaviors in a sample of

women at high risk for disordered eating behavior. Ultimately, by investigating these

relationships, the study sought to identify specific EMS that serve to mediate the relationship

between early experiences of emotional maltreatment and the development of ED behaviors. By

including a measure of depression in the model, this study aimed to provide further support for

existing theoretical and empirical evidence that, childhood emotional maltreatment is strongly

related to the emergence of depressive symptoms (Liu, et al., 2005, Rose & Abramson, 1992).

Additionally, cognitive behavior models of bulimia and binge eating include the presence of

negative mood symptoms as a potential precursor to engaging in maladaptive eating behaviors

(Agras & Apple, 2008; Fairburn, 2008). Therefore, it was hypothesized that depressive

symptoms would act as a mediator in the current study between emotional maltreatment and ED

symptoms, as in previous studies (see Kong & Bernstein, 2009). Finally, given previous research

suggesting specific EMS predict depressive symptomatology, it was hypothesized that the

current study would find similar associations. Ultimately, by identifying specific schemas

impacting the emergence and maintenance of depression and eating psychopathology among

maltreatment survivors, we move beyond simply recognizing the distal outcomes of emotional

maltreatment and begin to increase our understanding of how emotional maltreatment affects

development.

32

Significance

Considerable research indicates that a history of child maltreatment is associated with a

range of immediate and long-term consequences. Although previous studies have focused almost

exclusively on the outcomes of sexual and physical abuse, efforts to expand and refine our

understanding of childhood emotional maltreatment and its consequences support the association

between emotionally abusive experiences and a variety of negative outcomes. For example, a

history of CEA has been associated with numerous psychological and health-related problems

including increased anxiety, depression, posttraumatic stress, eating psychopathology,

personality disorders, substance abuse, low self-esteem, suicidality, and subsequent victimization

(Briere & Runtz, 1990; Finzi-Dottan & Karu, 2006; Gibb et al., 2001; Glaser, 2002; Hart,

Binggeli, & Brassard, 1998; Kent & Waller, 2000; Messman-Moore & Brown, 2004; Rodgers et

al., 2004; Rich et al., 2005; Sebre et al., 2004; Spertus et al., 2003). Although investigating the

impact of multiple abuse experiences is important, research examining the unique impact of

emotional maltreatment is useful, given that a considerable number of individuals endorse this

form of abuse at the exclusion of other abuse types. For example there is evidence that patients

exclusively endorsing emotional abuse display similar levels of depression, symptomatic

distress, and borderline personality features compared to clients reporting CSA or multiple forms

of abuse (Braver, Bumberry, Green, & Rawson, 1992).

As previously reviewed, there are several studies to date relating emotional maltreatment

and depressive symptomatology. However, of these studies, few have examined potential

mediators that may more fully explain this relationship. Given the pervasiveness of depression

and the myriad consequences including increased mortality (Penninx et al., 2001), decreased

physical health (for reviews see Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002), and given

33

that depression remains the leading cause of disability in the US (The World Health Report,

2004), identification of EMS may serve as modifiable targets for prevention and treatment of

depression.

Conversely, research examining emotional maltreatment and ED symptoms is limited

compared to studies investigating depression as an outcome. Still, understanding the

development and maintenance of EDs is particularly relevant given the frequency of these

behaviors in college women. In a longitudinal incidence study of EDs, results revealed a

continuous linear increase in eating disorder pathology for 15- to 24-year-old females (Lucas,

Crowson, O’Fallon, &Melton, 1999). It is estimated that 1-4% of female college students meet

the full DSM-IV (APA, 1994) criteria for AN or BN, with an additional 35-70% of women

reporting direct and indirect symptoms of disordered eating including loss of appetite control,

periodic use of laxatives, purging or excessive exercise to inhibit weight gain, body image

dissatisfaction and distortion, obsessive monitoring of caloric and fat content, unhealthy weight

fluctuations, excessive weight monitoring, moderate depression, and low self-esteem (Edwards-

Hewitt & Gray, 1993; Heatherton, Nichols, Mahamedi, & Keel, 1995; Nelson, Hughes, Katz, &

Searight, 1999;). Many of the women endorsing subclinical ED symptoms likely fall into the

EDNOS subtype, the most commonly diagnosed subtype with prevalence rates ranging as high

as 50% to 70% of all individuals with eating disorders (Ricca et al., 2001). Although there is

limited research on women with this diagnosis (Fairburn & Bohn, 2005) in part due to the

heterogeneity of this group, ED researchers suggest that in addition to being a common

diagnosis, the distress associated with these ED behaviors may be severe and persistent (Walsh

& Sysko, 2009). Given that a substantial portion of individuals exhibiting maladaptive ED

symptoms do not fit into the current DSM-IV diagnostic categories, as well as the high

34

prevalence of college women endorsing these symptoms, the current study attempted to extend

previous research to address these gaps by investigating ED symptoms (e.g., bingeing, purging,

restricting, and ED related cognitions including eating, weight, and shape concerns) separately,

as they relate to emotional maltreatment.

In addition to providing evidence for the relationship between child maltreatment and

eating psychopathology, particularly the influence of emotional maltreatment, it is important to

increase our understanding of the mechanisms that may more fully explain this distal

relationship. Recently, ED researchers have suggested that although disturbances in cognition

regarding eating, weight, and shape are necessary for understanding EDs, they are not sufficient

explanatory constructs (Fairburn, Cooper, & Shafran, 2003; Waller & Kennerley, 2003; Waller,

2006). Data from a recent study examining maladaptive core beliefs and ED symptoms supports

the idea that distorted cognitions not related to eating disorder psychopathology are present in

ED patients, especially those patients engaging in purging and restricting behaviors (Dingemans,

Spinhoven, van Furth, 2006). Efforts to replicate these results in a larger population of

maltreatment survivors is important. Furthermore, identifying particular schemas that mediate

the association between emotional maltreatment and ED behaviors not only provides additional

support for Young’s EMS taxonomy, but also specific schemata represent potentially modifiable

treatment targets. Effective treatment interventions are particularly necessary given that ED are

widely believed to be one of the most difficult psychological conditions to treat, not to mention

have the highest rate of mortality among mental disorders (Agras, 2001).

35

The Hypothesized Model

The current study proposed a model (see Figure 1) wherein the role of emotional

maltreatment and EMS were examined as they relate to subsequent depressive and ED

symptomatology. The model hypothesized that the presence and severity of emotional

maltreatment in a woman’s childhood and adolescence (i.e., before age 18) would result in

maladaptive schema elevations and subsequent increases in depressive and ED symptomatology.

Based on theoretical and empirical rationale, it was hypothesized that the domains of

Disconnection & Rejection and Impaired Autonomy would be most strongly related to emotional

maltreatment experiences. Although given preliminary findings supporting associations between

schemas in the domains of Other-Directedness and Overvigilance & Inhibition, significant

associations between these domains and emotional maltreatment were also hypothesized.

Similarly, previous studies have suggested that the domains of Disconnection & Rejection,

Impaired Autonomy, and Overvigilance & Inhibition are related to increased symptoms of

depression. Therefore, the current study hypothesized significant relations between these schema

domains and depression. Based on theory and limited empirical research, direct associations

between schemas comprising the Disconnection & Rejection domain, particularly Mistrust/Abuse

and Defectiveness/Shame and binge/purge behavior associated with BN were hypothesized.

Additionally, it was hypothesized that the Overvigilance & Inhibition domain, particularly the

Unrelenting Standards schema, would be related to ED cognitions and restricting behavior (i.e.,

Global Eating Psychopathology construct measured by the EDE-Q). Lastly, besides the final

hypothesis that the Impaired Limits schema domain would evidence the strongest correlation

with ED behaviors, particularly binge eating and purging behavior, additional hypotheses

36

regarding the relationship between EMS and ED symptoms were not made as these analyses

were more exploratory in nature.

In summary, specific direct and indirect effects were hypothesized and modeled in Figure

1. Overall, the current study was designed to test whether the relationship between emotional

maltreatment and depression was indirect through the influence of EMS. In turn, depressive

symptoms were expected to be related to ED symptomatology. Although the model depicts

indirect paths from EMS to ED behaviors via depression, it is certainly plausible that direct

relationships between emotional maltreatment and ED symptoms, as well as between EMS and

ED symptoms exist, although, ultimately, it was hypothesized that including depression would

improve the overall fit of the model

37

Global Eating

Psychopathology

Disconnection &

Rejection

Other

Directedness

Impaired

Autonomy

Impaired Limits

Overvigilance &

Inhibition

Emotional

Maltreatment

Depression

Binge Episodes

Purge Episodes

Figure 1. Hypothesized Structural Model relating emotional maltreatment, EMS, depressive, and ED symptoms. Latent variables are indicated by ellipses,

measured variables by rectangles.

38

CHAPTER 3

METHOD

Participants

Participants were 996 female students recruited from introductory psychology classes

through the research pool during the 2007-2008 academic year. Participation in the current study

fulfilled a research requirement; however, students were also given the opportunity to participate

in library research to fulfill their research requirement.

Measures

Emotional Maltreatment

The Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998) is a 28-item

retrospective self-report questionnaire designed to assess five types of childhood maltreatment

occurring before age 18 including sexual abuse, physical abuse, physical neglect, emotional

abuse, and emotional neglect. For the purposes of this study, only the emotional abuse and

neglect subscales each comprised of five items were used to measure experiences of emotional

maltreatment. Each item begins with the phrase, “When I was growing up,” and is rated on a

five-point Likert scale ranging from “Never true” to “Very often true.” The CTQ has

demonstrated reliability including moderate to high internal consistency reliability coefficients

ranging from α =. 66 to α = .92 across a range of samples, and test-retest reliability coefficients

ranging from .79 to .86 over an average of 4 months (Bernstein et al., 2003; Scher, Stein,

39

Asmundson, McCreary, & Forde, 2001). Alpha’s for the emotional abuse scale have been

reported between .84 and .89 and for the emotional neglect scale between .85 and .91 across both

community and clinical samples (Bernstein et al., 2003). In the present sample, Cronbach’s alpha

was .83 for the emotional abuse subscale and .84 for the emotional neglect subscale. The CTQ’s

validity has been supported by demonstrating convergent validity with ratings of childhood

maltreatment of both clinicians and therapists, and a consistent five-factor structure (Bernstein &

Fink, 1998; Bernstein et al., 2003; Fink et al., 1995; Scher Stein, Asmundson, McCreary, &

Forde, 2001). Clinical cut-off scores offered by the measure’s creator (Bernstein & Fink, 1998)

were used to report descriptive information about the current sample ( 9 and 10 for low to

moderate emotional abuse and neglect respectively; 13 and 15 for moderate to severe

emotional abuse and neglect).

Adverse Child Experiences Study Questionnaire (ACE). Seven additional questions were

used to assess emotional maltreatment. Questions were drawn from a larger questionnaire used in

the Adverse Childhood Experiences (ACE) Study based at Kaiser Permanente’s San Diego

Health Appraisal Clinic and approved by institutional review boards of Kaiser Permanente and

the Office of Protection from Research Risks at the National Institutes of Health. The ACE Study

assessed retrospectively and prospectively, the long-term impact of abuse and household

dysfunction during childhood on a variety of outcomes. Questions were adapted from the

Conflicts Tactics Scale (CTS; Straus, 1990), a commonly used measure in the field of family

violence to assess psychological abuse in childhood. All questions referred to the respondents’

first 18 years of life and assessed both the frequency and perpetrator of the experiences of

emotional abuse and neglect. Sample questions included, “Were you treated in a cold, uncaring

40

way or made to feel like you were not loved,” and “Were you often put down or ridiculed.”

Cronbach’s alpha was .77 in the current sample.

Early Maladaptive Schemas

The Young Schema Questionnaire––short form (YSQ; Young, 1994) contains 75 items

rated on a 6-point scale, ranging from 1 (completely untrue of me) to 6, (describes me perfectly).

These items belong to one of 15 rationally derived categories of EMS (see Table 1). The first

psychometric evaluation of the YSQ (in undergraduate and adult samples) demonstrated

adequate test–retest reliability, (coefficients ranging from .50 to.82) and internal consistency

(alpha coefficients ranging from .83 to .96) (Schmidt et al., 1995). Cronbach’s alpha for the

current sample was .96. A longitudinal psychometric evaluation of the YSQ in a large sample of

adolescents suggests good test–retest reliability for EMS over a 1-year period (retest correlations

from .48 to .69).

Depressive Symptoms

The Beck Depression Inventory-II (BDI-II; Beck, Brown, & Steer, 1988) is a 21-item

self-report measure of the cognitive, affective, motivational, and somatic symptoms of

depression. For each item, participants are asked to rate how they felt during the past week with

higher scores indicating greater severity of current depressive symptoms. Beck and colleagues

(1996) reported a coefficient alpha of .92 for an outpatient sample (n = 500) and a coefficient

alpha of .93 for a college student sample (n = 120). Cronbach’s alpha for the current sample was

.92. Regarding concurrent validity, BDI-II scores are positively correlated with the Scale for

Suicide Ideation (r =. 37), the Beck Hopelessness Scale (r = .68), the Hamilton Psychiatric

Rating Scale for Depression (r =. 71), and the Hamilton Rating Scale for Anxiety (r =. 47).

41

Trauma Symptom Inventory- Depression Subscale (TSI; Briere, 1995). The 13-item

depression subscale of the larger 100-item self-report inventory was used to measure depressive

symptoms. Participants rate the presence of each symptom according to its frequency of

occurrence over the prior six months, using a four-point scale ranging from 0 (never) to 3 (often).

Although the TSI does not generate DSM-IV diagnoses, it is designed to evaluate the severity of

posttraumatic distress, including the presence of depressive symptomatology, both in terms of

mood state and depressive cognitive distortions. The TSI has demonstrated good internal

consistency with mean ranging from 0.84 to 0.87 in a variety of both clinical and nonclinical

samples. Cronbach’s alpha for the depression subscale was .90 in the present sample. The TSI

has been shown to exhibit good convergent, predictive, and incremental validity.

Eating Disorder Symptomatology.

Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994) is a 41-

item self-report measure adapted from the Eating Disorder Examination, a structured interview

to assess eating disorder symptoms (Fairburn, 1993). Although this questionnaire may be used to

make preliminary diagnoses of anorexia nervosa or bulimia nervosa, this measure was not used

for this purpose in the current study. Instead, in an effort to examine a variety of ED behavior,

the four major subscales of the EDE-Q (e.g., Dietary Restraint (DR), Eating Concern (EC),

Weight Concern (WC), and Shape Concern (SC)) are averaged to yield a Global Score, which in

the current study represented the latent construct entitled Global Eating Pathology. Frequencies

of binge eating and compensatory strategies (e.g., self-induced vomiting, laxative and diuretic

misuse) were also assessed in terms of the number of episodes occurring during the past four

weeks and are not included in the Global Score. The four major subscales have demonstrated

excellent internal consistency and test-retest reliability over a two-week time period (Luce &

42

Crowther, 1999). More recently, normative data for undergraduate women indicated internal

consistencies range from .78 for EC to .93 for SC, which was similar to the present sample which

had a Cronbach’s alpha of .93. Test-retest correlations range from .81 to .94 for the four

subscales and from .57 to .70 for the frequency of key behavioral features, including binge

eating, self-induced vomiting, and laxative misuse (Luce, Crowther, & Pole, 2008). Although the

binge and compensatory behaviors appear less reliable, this may be explained by lower

frequencies of these behaviors among non-clinical populations, or potentially a represent a true

change in onset and remission of these behaviors (Luce & Crowther, 1999).

Procedure

As previously indicated, participants were recruited through the research pool. The

researcher began each data collection session with a thorough review of the consent form. In an

effort to maximize honest disclosure regarding sensitive information, students were guaranteed

anonymity. After obtaining informed consent and reinforcing participants’ anonymity and right

to withdraw from the study at any time without penalty, the researcher provided an opportunity

for students to ask any additional questions. After all remaining questions were adequately

answered, surveys were administered.

Once the questionnaire packet was returned to the researcher, the participants were asked

to read a debriefing form explaining the purpose of the study in more detail. Any additional

questions or concerns were addressed at this time. Participants were also given a list of referrals

in the event of future difficulties or distress associated with participation in the current study.

Participants were also encouraged to contact the researcher with additional questions should they

arise.

43

To ensure anonymity, signed consent forms were separated from completed surveys upon

collection and stored in a separate room. The completed surveys did not contain any identifying

information. Lastly, students were granted research credit using the information provided on the

consent form regardless of survey completion.

Data Analytic Plan

Structural equation modeling (SEM) was performed using Analysis of Momentary

Structure 17.0 (AMOS 17.0; Arbuckle, 2009) to examine the proposed model and mediational

hypotheses. SEM was selected because of its several advantages over regression modeling: (1)

use of confirmatory factor analysis to reduce measurement error by utilizing multiple indicators

per latent variable, (2) increased flexibility regarding assumptions (in particular allowing

interpretation in the presence of multicollinearity), (3) the ability to test models with multiple

dependent variables, (4) the ability to compare alternative models to assess relative model fit

with fit indices offered as a measure of how accurately the hypothesized model(s) fit the data

(Kline, 2005).

Sample Size and Power

Several recommendations regarding sample size are provided within the literature in an

effort to ensure adequate power. For example, Mitchell (1993) suggests that there be 10 to 20

times as many cases as variable. Another rule of thumb, based on Stevens (2002), is to have at

least 15 cases per measured variable or indicator. For the current study, which has 41 indicators,

a sample size range of 615 women (based on 15 cases per indicator) to 820 women (based on 20

cases per indicator) are recommended. Notably, a minimum of 861 women is required to

compute the covariance matrix (based on the formula k (k+1)/2 observations, where k is the

44

number of variables). Furthermore, it is recommended that the researcher exceed the minimum

sample size recommendations particularly when data are non-normal (Kline, 2005). Therefore,

the current sample size of over 900 participants appears to exceed current suggestions with

regard to obtaining a modal power level of .8 (Cohen, 1988).

Missing Data

In order to account for missing data, the maximum likelihood (ML) missing data

imputation procedure was used. This method is robust against moderate violations of normality,

however, skewness and kurtosis may lead to an overestimation of the chi-square fit index,

making model rejection more likely (West, Finch, & Curran, 1995). Compared to other methods

available, (e.g., pairwise and listwise deletion), ML estimates are unbiased and have a reduced

likelihood of convergence failure (Enders & Bandalos, 2001; Gold & Bentler, 2000). Notably,

less than 5% of all items were missing and analyses indicated that the data was missing at

random.

Latent Constructs and Corresponding Indicators

A parceling technique was used to create indicators for many of the latent constructs

investigated (See Figure 2). For example, items from the emotional abuse and emotion neglect

subscales of the CTQ were used to create three emotional maltreatment parcels. Items

comprising each scale were assigned randomly to one of the parcels, and item scores were

averaged to compute parcel scores. In addition to the three parcels, the emotional maltreatment

construct was indicated by a frequency count of items endorsed on the ACE questionnaire. Each

of the five schema domains (i.e., Disconnection & Rejection, Impaired Autonomy &

Performance, Impaired Limits, Other Directedness, and Overvigilance & Inhibition) were

45

indicated by five parcels created by randomly assigning individual items from the subscales that

comprise the larger domain (see Table 1 for specific subscale names and descriptions). The latent

construct entitled Global Eating Pathology is indicated by four parcels comprised of items from

the Weight Concern, Shape Concern, and Eating Concern subscales of the EDE-Q as well as the

Dietary Restraint subscale of the EDE-Q. The frequency of Binge Episodes and Purge Episodes

were modeled separately as measured variables because they represent frequency counts of ED

behaviors which are not captured in the EDE-Q Global Score. Finally, depressive

symptomatology is indicated by three parcels of items from the BDI as well as by the depression

subscale of the TSI.

Parceling was used often to increase reliability. The reliability of a parcel of items is

greater than that of a single item, so parcels can serve as more stable indicators of a latent

construct. Additionally, the risk of spurious correlations is reduced, both because fewer

correlations are being estimated and because each estimate is based on more stable indicators.

Finally, parcels have been shown to provide more efficient estimates of latent parameters than do

items (Kline, 2005)

46

Global Eating Psychopathology

Disconnection & Rejection

Other Directedness

Impaired Autonomy

Impaired Limits

Overvigilance & Inhibition


Depression

Binge Episodes

Purge Episodes

EM1

EM2

EM3

EM4

EM5

YS1 YS2 YS3 YS4 YS5 YS6 YS7 YS8 YS9 YS15 YS10 YS11 YS12 YS13 YS14

ED1

ED2

ED3

ED4

BDI1 BDI2 BDI3 TSI-D

YS16 YS17 YS18 YS19 YS20 YS21 YS22 YS23

YS24 YS25

ACE

.86 .92 .93 .94 .92

.83 .88 .90 .87

.86

.78 .80 .69 .73 .52

.72 .78 .80 .82 .85

.73 .79 .86 .78 .84

.92 .90 .88 .77

.77

.75

.85

.83

.84

.79

.91

.93

.94

.95

Figure 2. Measurement model. All parameter estimates are standardized and significant at p < .01.

47

Measurement model

Several researchers have argued for a two-step approach to structural equation modeling

where the measurement model is initially tested and, if necessary, respecified before testing the

structural model (See Anderson & Gebing, 1988; Kline, 2005). Confirmatory factor analysis

(CFA) was used to determine if the measurement model (see Figure 2) adequately fit the data by

assessing the relationships between the latent constructs and observed indicators. Of interest is

the factor loading of the observed indicator on the construct of interest, as well as overall model

fit. The proposed measurement model consisted of eight latent variables (i.e., Emotional

Maltreatment, Early Maladaptive Schema Domains, Depression, and Global Eating

Psychopathology), each with four or more indicators, and two measured variables (Binge

Episodes and Purge Episodes).

Specification of CFA model. CFA models must meet necessary standards in order to be

identified. Standard guidelines suggest that CFA models are identified if they contain two or

more factors with at least two indicators, referred to by Bollen (1989) as the two-indicator rule.

Although some researchers suggest that this rule is oversimplified and that models containing

factors with only two indicators are more prone to estimation problems, this appears to be only in

situations where the sample size is small (i.e., less than 200) (See Kline, 2005). As is common

practice in path modeling, measurement errors in the proposed CFA model were assigned a scale

through a unit loading identification (UCI) constraint. Specifically, the unstandardized residual

path coefficient for the direct effect of a measurement error on the corresponding indicator was

fixed to 1.0 (Kline, 2005). Although it was generally expected that indicators would be

correlated with several factors, it is hypothesized that they would demonstrate higher estimated

48

correlations with the factors they are believed to measure (see Graham, Guthrie, & Thompson,

2003; Kline, 2005). Finally, it was anticipated that the proposed CFA model would adequately fit

the data; however, re-specification efforts were utilized as necessary. For example, sometimes

indicators demonstrate poor loadings on the factors to which they were originally assigned.

Inspection of residuals can help identify another factor to which the indicator may be switched.

Similarly, an indicator may have relatively high loadings on multiple factors suggesting the

indicator in question measures more than one construct. This may be dealt with by either

allowing the indicator to load onto multiple factors or by allowing the measurement errors to

covary, as was done in the current study (Kline, 2005).

Consistent with recommendations (See Kline, 2005) multiple fit indices were utilized to

determine if the measurement model effectively accounted for the underlying latent data

structure by converging to adequately reproduce the covariance matrix. First, the chi-square

statistic, the traditional fit index, which reflects the amount of discrepancy between the implied

and observed covariance matrices was computed. A statistically non-significant chi-square fit

index should suggest a well-fitting model and rejection of a model would result from a

statistically significant chi-square. Given that this method is considered stringent and heavily

dependent on sample size resulting in the rejection of adequate fitting models (Bentler & Bonett,

1980), the chi-square statistic was supplemented with additional indexes of fit. The following

indices and cutoffs were used to determine model fit in this study (Marsh, Hau, & Wen, 2004;

Vandenberg & Lance, 2000): root mean square error of approximation (RMSEA; .08 or less

represents acceptable fit; Steiger, 1990), non-normed fit index (NNFI; .90 or higher indicates that

the model cannot likely be significantly improved upon; Bentler & Bonett, 1980) (same as

Tucker-Lewis Index), and the comparative fit index (CFI; .90 or higher represents acceptable fit;

49

Bentler, 1990). These indices differentiate between well-fitting and poor-fitting models by

considering degrees of freedom, model complexity, model misspecifications, sample size, and

potential for replication (see review by Vandenberg & Lance, 2000).

Structural model

Upon specifying the appropriate measurement model, the proposed structural model was

evaluated in order to examine indirect and direct relationships among latent constructs as well as

determine the fit of the model. As indicated above, SEM was used to test the hypothesized

relations between emotional maltreatment, EMS domains, depression, and ED behaviors. The

proposed hypothesized structural model shown in Figure 1 was tested and compared to four

alternative models in an effort to test meditational hypotheses. More specifically, Model 1 (see

Figure 1) depicts the full model with hypothesized paths based on previous theoretical and

empirical findings depicted by arrows. Structural Model 2 and 3 constrained to zero the direct

paths from emotional maltreatment to depression and ED symptoms, respectively. With respect

to emotional maltreatment, these models assessed the mediating role of EMS separately for

depressive and ED symptoms. Structural Model 4 deleted the direct path from EMS to ED

symptoms in order to examine whether the association between maladaptive schemas and eating

psychopathology was mediated by symptoms of depression. In an effort to further examine the

mediating role of depression, pathways to and from the mediator (i.e., from emotional

maltreatment to depression and from depression to ED symptoms) were removed in Structural

Model 5. Finally, Structural Model 6 was tested in which all paths that did not significantly

contribute to the fit of the hypothesized model were removed.

50

CHAPTER 4

RESULTS

Sample Characteristics

Mean age of the 996 participants was 18.98 years (SD = 1.52). Participants were

predominately Caucasian (79.7%; n=794), while 9.43% (n=94) identified as African American,

8.03% (n=80) as Asian, and 2.51% (n=25) as Latina. Over half the sample reported a gross

family income of over $60,000, with 40% of participants (n=352) reporting family income of

over $80,000. With regard to maltreatment history, 240 (24.1%) women endorsed experiences of

emotional abuse, of which 92 (9.2%) women reported moderate to severe emotional abuse.

Experiences of emotional neglect were reported by 204 (20.5%) women, with 46 (4.6%) women

endorsing moderate to severe emotional neglect. See Table 3 for mean, standard deviation, and

bivariate correlations for study variables. Regarding ED symptoms, a potential concern in a

nonclinical, undergraduate sample is the possibility for restricted range in EDE-Q scores.

Previous research has, however, demonstrated that undergraduate women endorse moderate to

high levels of ED pathology (Green et al., 2009), and the current sample appears to be no

exception. Descriptive statistics indicate scores on the EDE-Q ranged from .00 to 5.76, with 25%

of women in the sample obtaining scores above 3.00. These scores are consistent with studies

including undergraduate samples, as well as with larger epidemiological studies (see Green et al.,

2009; Mond, Hay, Rogers, & Owen, 2006) and alleviate EDE-Q restricted range concerns in this

nonclinical sample.

51

Intercorrelations between study variables indicated that emotional abuse and neglect were

significantly correlated with all study variables except frequency of purging. All schema

domains were significantly associated with emotional maltreatment. As hypothesized, the

schema domain of Disconnection & Rejection was more strongly related to indicators of

emotional maltreatment than were other domains. Although the Impaired Autonomy schema

domain was significantly associated with emotional maltreatment, the strength of the association

was to a lesser degree than hypothesized. Schema domains were significantly correlated with

each other, as well as with depression, global ED symptoms, and binge behavior, but not with

frequency of purging. With regard to specific hypotheses, results confirmed that the schema

domains of Disconnection & Rejection and Impaired Autonomy evidenced the strongest

associations to depression. Contrary to expectations, the domain of Impaired Limits showed a

stronger association with depression (as measured by the BDI) than did Overvigilance &

Inhibition. The Disconnection & Rejection domain was most strongly associated with both

global ED symptoms and binge behavior. Meanwhile the Impaired Limits domain, although

significantly correlated to global ED symptoms and binge episodes, did not evidence the strength

of association to ED symptoms predicted, particularly given a non-significant association to

purge behavior. As hypothesized, depressive symptoms as measured by the BDI and TSI

depression subscale were significantly associated with all eating disorder variables.

52

Table 2

Means, Standard Deviations, and Bivariate Correlations of Study Variables

1 2 3 4 5 6 7 8 9 10 11 12 13

1. CEA -- .672** .601** .489** .336** .196** .347** .233** .341** .374** .230** .140** .027

2. CEN -- .450** .548** .363** .197** .301** .223** .344** .352** .137** .148** .065*

3. ACE -- .362** .258** .173** .231** .190** .294** .261** .178** .051 .000

4. D1 -- .718** .464** .558** .510** .615** .644** .315** .196** .050

5. D2 -- .472** .552** .392** .609** .564** .340** .132** .020

6. D3 -- .343** .385** .405** .297** .225** .190** .026

7. D4 -- .453** .471** .558** .282** .152** .060

8. D5 -- .352** .310** .205** .122** .007

9. BDI -- .734** .448** .214** .104**

10. TSI-Dep -- .357** .150** .069*

11. Global ED -- .272** .192**

12. Binge -- .231**

13. Purge --

M 7.39 7.41 .20 43.7 31.3 21.3 23.4 26.8 10.1 6.48 2.05 1.45 .297

SD 3.50 3.20 .40 19.7 12.0 8.13 8.33 8.64 8.66 5.01 1.33 2.97 2.05

Note. D1 = Disconnection Rejection Schema Domain; D2 = Impaired Autonomy & Performance Schema Domain; D3 = Impaired Limits Schema Domain; D4 = Other Directedness Schema

Domain; D5 = Overvigilance & Inhibition Schema Domain. * p < .05; ** p < .01

53

Structural Equation Modeling

A measurement model was first tested for an acceptable fit to the data using confirmatory

factor analysis (Anderson & Gerbing, 1988). Once a measurement model was estimated, a

structural model was tested using the maximum likelihood method in AMOS (version 17.0).

Criteria for acceptable model fit were a comparative fit index (CFI) greater than or equal to .90,

and a root mean square error of approximation (RMSEA) of .08 or less (Hu & Bentler, 1999;

Kline, 2011). See Table 3 for additional fit indices. The chi-square (2) difference test was used

to compare nested models (Steiger, Shapiro, & Browne, 1985).

Measurement Model

As previously described, many of the latent variables were indicated by parcels of items

in an effort to more closely approximate continuous measurement of the latent construct.

Initially, the measurement model (see Figure 2) was tested without allowing the schema domains

and ED variables to correlate (i.e., without allowing schema domain to correlate with other

schemas and binge, purge, and global eating constructs to correlate with each other). This

resulted in a poor fitting model (2 = 6214.8, df = 781; CFI = .843, RMSEA = .084). The second

measurement model, which allowed for the correlation of error terms among variables

theoretically and empirically linked, adequately fit the data (2 = 3980.6, df = 769; CFI = .907,

RMSEA = .065). Fit indices for both measurement models are presented in Table 3. All of the

loadings of the latent and measured variables were significant (p < .001). Hence, all the latent

variables were adequately measured by their respective indicators (See Figure 2). Consequently,

this measurement model was used in subsequent analyses.

54

Table 3

Summary of Model Fit Indices

1. Measurement Model 1 6214.80 781 .084 .825 .843 2. Measurement Model 2 3980.62 769 .065 .888 .907 3. Structural Model 1: 2678.10 750 .051 .924 .944 Full Model

4. Structural Model 2: 2681.58 751 .051 .924 .944 Minus direct path from EM to Depression 5. Structural Model 3: 2679.40 753 .051 .924 .944 Minus direct paths from EM to ED 6. Structural Model 4: 2694.11 755 .051 .924 .944 Minus direct paths from EMS to ED

7. Structural Model 5: 2823.54 754 .053 .920 .940 Minus direct paths from Depression to ED 8. Structural Model 6: 2684.01 758 .051 .924 .944 Minus non-significant paths

Model 2

df RMSEA NFI CFI

55

Structural Models

Structural Model 1: Target model including all hypothesized paths. The first structural

model analyzed was the full model (presented in Figure 3). This model depicts the hypothesized

relationships between emotional maltreatment, schema domains, depression, and ED symptoms

based on previous theoretical and empirical findings. Results indicated that this model provided a

good fit for the data (CFI = .944, RMSEA = .051). See Table 3 for additional fit statistics.

Emotional maltreatment was significantly related to all schema domains hypothesized

(i.e., Disconnection & Rejection, Impaired Autonomy, Other Directedness, and Overvigilance &

Inhibition). Similarly, Disconnection & Rejection and Impaired Autonomy schema domains were

significantly associated to depression as predicted; however, contrary to expectations, the

Overvigilance & Inhibition schema domain was not significantly related to depression or to

global ED symptoms. In fact, the only significant, hypothesized link between schema domains

and ED symptoms existed between Impaired Limits and Binge Episodes ( = .12, p < .05). All

other relationships between schema domains and ED symptoms were indirect through

depression, which was significantly related to all three ED variables but most strongly with

global ED psychopathology ( = .45, p < .05). Although emotional maltreatment was predicted

to be distally related to ED symptomatology, results confirmed that this relationship is not direct,

as emotional maltreatment did not significantly predict global ED symptoms, binge, or purge

behavior.

56



Other Directedness

Impaired Autonomy

Impaired Limits



Depression

Binge Episodes

Purge Episodes

.55**

.21**

.36**

.35**

.34**

.38**

.01ns

.16**

.45**

.13*

.04ns

.02ns

-.01ns

.06*

.02ns

-.04ns

.34** .12**

-.02ns

.06ns

Figure 3. Structural Model 1: Target model including all hypothesized paths. Standardized regression weights are presented for the direct paths and indirect

paths hypothesized. Note. *p < .05; **p < .01.

57

Structural Model 2: Test of mediating role of schema domains in the emotional

maltreatment-depression relationship. This model is identical to Structural Model 1, except that

the path from emotional maltreatment to depression was deleted in an effort to test the mediating

role of specific schema domains. The model fit the data well, evidencing identical CFI and

RMSEA values as Structural Model 1 (See Table 3 for additional fit indices). The Overvigilance

& Inhibition schema domain remained a non-significant predictor of depression in this model as

it was in Structural Model 1. The fit of this nested model was compared with the fit of the full

model using the chi-square difference test. Results indicated that the more parsimonious model,

Structural Model 2, was roughly equivalent to Structural Model 1 (2

diff = 3.47, df = 1, p > .05).

Given the non signficant 2

difference value, the direct path from emotional maltreatment to

depressive symptoms does not contribute significantly to model fit. Therefore, findings support

the mediating role of Disconnection & Rejection and Impaired Autonomy schema domains.

58



Other Directedness

Impaired Autonomy

Impaired Limits



Depression

Binge Episodes

Purge Episodes

.55**

.21**

.37**

.35**

.34**

.36**

.02ns

.16**

.45**

.13*

.04ns

.02ns

-.01ns

.02ns

-.04ns

.38** .12**

-.02ns

.06ns

Figure 4. Structural Model 2: Test of the mediating role of schema domains in the emotional maltreatment-depression relationship. Standardized regression

weights are presented for the direct paths and indirect paths hypothesized. Note. *p < .05; **p < .01.

59

Structural Model 3: Test of mediating role of schema domains in the emotional

maltreatment-eating symptomatology relationship. Just as the path from emotional maltreatment

to depression was deleted in Structural Model 2, in Structural Model 3, the paths from emotional

maltreatment to ED symptomatology were constrained to zero to test the mediating role of EMS

in the relationship between emotional maltreatment and eating symptomatology. This model fit

the data well, evidencing similar fit indices as the two previous models (CFI = .944, RMSEA =

.051). A non significant 2 difference value (

2diff = 1.30, df = 3, p > .05) suggests that the direct

paths from emotional maltreatment to ED symptoms do not contribute significantly to model fit.

Given that the paths from emotional maltreatment to Global Eating Psychopathology, Binge

Episodes, and Purge Episodes were non-significant in Structural Model 1, it is not surprising that

the impact of constraining these paths to zero was negligible. Findings suggest that the

Disconnection & Rejection schema domain plays a mediating role in the relationship between

emotional maltreatment and both frequency of Binge Episodes and Purge Episodes. Given that

the association between Overvigilance & Inhibition and Global Eating Psychopathology

remained non-significant in this model, mediation was no longer considered.

60



Other Directedness

Impaired Autonomy

Impaired Limits



Depression

Binge Episodes

Purge Episodes

.55**

.21**

.36**

.35**

.34**

.38**

.02ns

.16**

.44**

.14*

.06*

.05ns

-.03ns

.34** .12**

-.03ns

.05ns

Figure 5. Structural Model 3: Test of the mediating role of schema domains in the emotional maltreatment-eating symptomatology relationship. Standardized

regression weights are presented for the direct paths and indirect paths hypothesized. Note. *p < .05; **p < .01.

61

Structural Model 4:Test of mediating role of depression in relationships between schema

domains and eating symptomatology. This model is identical to Structural Model 1 except that

the paths from the schema domains (i.e., Disconnection & Rejection and Overvigilance &

Inhibition) to ED symptomatology were removed to test the mediating role of depression in the

relationships between schema domains and eating symptomatology. This model fit the data well

and demonstrated similar fit indices to Structural Model 1 (See Table 3 ). Results from the chi-

square difference test (2

diff = 3.30, df = 3, p > .05) indicated the nested model is equally

acceptable when compared to the full model, albeit more parsimonious. Further, results provide

support for the mediating role of depression. In other words, the relation between schemas and

ED symptomatology appears to be indirect through depression.

62



Other Directedness

Impaired Autonomy

Impaired Limits



Depression

Binge Episodes

Purge Episodes

.55**

.21**

.36**

.35**

.38**

.02ns

.17**

.47**

.12*

.04ns

.02ns

.01ns

.06*

.34** .13**

-.04ns

Figure 6. Structural Model 4: Test of mediating role of depression in relationships between schema domains and ED symptomatology. Standardized

regression weights are presented for the direct paths and indirect paths hypothesized. Note. *p < .05; **p < .01.

63

Structural Model 5:Further assessment of the mediating role of depression. In this model,

the pathways to and from the mediator (i.e., from emotional maltreatment to depression and from

depression to ED symptoms) were deleted, as recommended by Holmbeck (1997). This model

was tested in an effort to determine if the removal of these pathways affected the direct

relationship between emotional maltreatment and ED symptoms, which to this point had

remained non-significant in all previous models. Although the relationship between emotional

maltreatment and global ED symptoms was significant in this model ( = .13, p < .05), the chi-

square difference test indicated that the full model, Structural Model 1, was a better fit to the data

(2

diff = 145.4, df = 4, p < .001). The significant chi-square difference test provides further

support for the mediating influence of depression.

64



Other Directedness

Impaired Autonomy

Impaired Limits



Depression

Binge Episodes

Purge Episodes

.55**

.21**

.36**

.35**

.34**

.35**

.04ns

.01ns

.04ns

.13

.01ns

.02ns

.39** .12**

-.01ns

.24

Figure 7. Structural Model 5: Further assessment of the mediating role of depression. Standardized regression weights are presented for the direct paths and

indirect paths hypothesized. Note. *p < .05; **p < .01.

65

Structural Model 6:Final model with non-significant paths deleted. The final model

tested removed all non-significant pathways present in the full model (See Figure 4). This model

fit the data well (CFI = .944, RMSEA = .051) and when compared to Structural Model 1, a non-

significant chi-square difference test (2

diff = 5.90, df = 8, p > .05), suggests that this model is an

equally good fit to the data statistically. All paths significant in the full model, Structural Model

1, remained significant in this model and the magnitude of the path coefficients changed

minimally.

66



Other Directedness

Impaired Autonomy

Impaired Limits



Depression

Binge Episodes

Purge Episodes

.55**

.21**

.36**

.35**

.34**

.39**

.19**

.47**

.10*

.06*

.34** .12*

Figure 8. Structural Model 6:Final model with non-significant paths deleted. Standardized regression weights are presented for the direct paths and indirect

paths hypothesized. Note. *p < .05; **p < .01.

67

CHAPTER 5

DISCUSSION

The results of the present study supplement an emerging literature providing evidence for

the enduring effects of emotional maltreatment. In the first study to investigate the relationships

among emotional maltreatment, maladaptive schemas, depression, and disordered eating

behaviors in a sample of women at high risk for ED behavior, results support a model where the

relationship between emotional maltreatment and disordered eating behaviors is indirect through

the influence of schemas and depression. These results, although preliminary, integrate and

expand on previous studies investigating the distal relationship between emotional abuse and

neglect in childhood and adult psychopathology.

Notably, emotional maltreatment did not evidence a direct relationship with any of the

ED outcome variables, except when depression was removed entirely from the model as seen in

Structural Model 5, where a small association was seen between emotional maltreatment and

Global Eating Psychopathology. This finding was consistent with hypotheses regarding the

indirect nature of this potentially distal relationship between emotional maltreatment and ED

symptomatology. Although Kennedy and colleagues (2007) found a direct and unmediated

relationship between emotional abuse and disordered eating, other studies have found not found

support for a direct link (Kent et al., 1999; Mazzeo & Espelage, 2002). Notably, the study that

found a direct link, did so in a sample comprised of both men and women. Results from studies

that have examined the association between emotional maltreatment and ED symptomatology, in

addition to various mediators (e.g., depression, anxiety, dissociation), among women generally

68

point to a weak, but significant indirect relationship. Therefore, it appears that further research is

necessary to better understand the nature of this relationship.

It appears that both explicit statements about a child’s worth in addition to indirect forms

of invalidation become internalized, subsequently serving as the foundation for negative

cognitions that contribute to the onset of depression (Rose & Abramson, 1992). Depressive

symptoms, particularly negative affect and low self-esteem, are then posited to lead to

maladaptive cognitions and behaviors that serve to elicit or maintain weight and shape concerns

as well as drive binge/purge behaviors. Although the link between depression and ED has been

established (Agras & Apple, 2008; Fairburn, 2008; Herzog, Keller, Sacks, Yeh, & Lavori, 1992;

Polivy & Herman, 2002; Wilksch & Wade, 2004), few studies have provided support for the

mediating influence of depression in the relationship between emotional maltreatment and ED

symptoms (Hund & Espelage, 2006; Mazzeo & Espelage, 2002).

Equally noteworthy was the strength of the association between emotional maltreatment

and Disconnection & Rejection. This direct path remained the strongest path across all models

examined. This is important because, although Young theorizes that this domain reflects

individuals where the family of origin is often cold, invalidating, and potentially abusive, limited

empirical evidence exists. To date, only a handful of studies have investigated the relationship

between emotional maltreatment and early maladaptive schemas, of which the majority included

only specific schema subscales such as Mistrust/Abuse, Defectiveness/Shame, and Emotional

Deprivation. Consistent with hypotheses, women endorsing a history of emotional maltreatment

reported significant associations with the schema domains of Impaired Autonomy, Other-

Directedness, and Overvigilance. The finding that emotional maltreatment was significantly

associated with multiple schema domains may suggest that early abuse experiences initiate more

69

pervasive dysfunctional thoughts and emotions represented by multiple schema domains, rather

than demonstrating schema specificity. However, this finding may also be explained by the high

correlations observed between schema domains. Although the majority of research has examined

the influence of particular schema subscales rather than associations present at the domain level,

YSQ validation studies, in addition to a recent study (Roemmele & Messman-Moore, 2011),

report similar intercorrelations between schemas domains as were found in the current study

(Hoffart et al., 2006; Roemmele & Messman-Moore, 2011).

In addition to support for the mediating role of depression, results also suggest that

schemas serve a mediating role in the emotional maltreatment-depression relationship. More

specifically, an indirect relationship through the schema domains of Disconnection & Rejection

and Impaired Autonomy was observed. It is certainly plausible that experiences of emotional

maltreatment would activate the belief that others are not reliable sources of support and

emotional validation, let alone potentially dangerous, leading to further thoughts of one’s own

inadequacy and defectiveness as reflected by the various schema subscales that comprise both of

these domains (e.g., Emotional Deprivation, Defectiveness/Shame, Mistrust/Abuse, Failure,

Vulnerability to Harm). Theoretically, these negative internal attributions and cognitions trigger

symptoms of depressions, as observed in this study as well as in previous research (Harris &

Curtin, 2002; Lumley & Harkness, 2007; O’Dougherty Wright, Crawford, & Del Castillo, 2009).

The association between the schema domains of Disconnection & Rejection and Impaired

Autonomy and depression replicate findings from previous research, particularly a recent study

that examined links between depression and domain-level EMS (see Halvorsen et al., 2009).

However, this is the only study to date to support these domain associations with depression in a

child maltreatment sample.

70

The only significant relationship between any schema domain and ED symptoms was

observed between the Impaired Limits schema domain and Binge Episodes, and it was a small

relationship at that. This was certainly contrary to hypotheses, although it is important to

recognize that only a couple of paths were modeled based on previous literature (i.e., paths were

hypothesized between Disconnection & Rejection and Impaired Limits to both Binge and Purge

Episodes, and from Overvigilance & Inhibition to Global Eating Psychopathology). More

recently, additional support for the relationship between subscales in domains not tested in this

study (i.e., Impaired Autonomy) and ED subgroups has been shown (Unoka, Tolgyes, Czobor, &

Simon, 2010). Although the present sample was not a clinical sample, one- fourth of the sample

endorsed significant eating pathology and was similar to undergraduate samples utilized in

previous studies as indicated above. Still, it is certainly possible that the lack of significant

relationships observed is in part due to the sub-threshold symptoms exhibited by a large portion

of the sample. Furthermore, in addition to using clinical samples, recent studies have examined

the utility of schemas in differentiating between specific ED subtypes (i.e., Anorexia Nervosa-

restricting subtype, Anorexia Nervosa-binge/purge subtype, Bulimia Nervosa), rather than

looking at specific ED behaviors or general cognitions as was done in this study (See Unoka,

Tolgyes, & Czobor, 2007; Unoka et al., 2010). Although these studies extend research

investigating the relation between EMS and eating psychopathology, a recent study provides

evidence that the clinical utility of the DSM-IV Anorexia Nervosa and Bulimia Nervosa

subtypes is questionable given both infrequent subtype use and adequate inter-rater agreement

(Thomas et al., 2010). This finding, coupled with previous research suggesting that emotional

maltreatment may be a risk factor for the development of more general ED symptomatology

(Kent & Waller, 2000), and limited empirical research examining the relationship between EMS

71

and ED behaviors, the current study’s emphasis on ED behaviors rather than diagnostic subtypes

remains a logical first step.

Several limitations of the current study should be noted. First, although the models

examined in this study provided an adequate fit to the data, these findings are preliminary,

require further replication, and do not imply that the model has been “proven” (Kline, 2005).

Given recent evidence that particular schema subscales predict subgroups of ED, further

examination of the schema-ED relationship is necessary, particularly at the schema subscale

level. Given that this was the first study to examine emotional maltreatment, early maladaptive

schemas, depression, and ED symptomatology simultaneously using SEM, specific hypotheses

regarding the influence of specific schema subscales was beyond the scope of the current study.

Although the structural equation modeling results imply the possibility of causality, the design

was cross-sectional and correlational in nature. Therefore, without longitudinal designs,

definitive conclusions about the temporal sequence of variables in the models presented in this

study and the causality of ED behaviors cannot be determined. Additionally, exclusive reliance

on self-report measures, particularly regarding potentially distal events, results in mono-method

and recall bias. Furthermore, given that respondents were asked to report about potentially

difficult experiences and the subsequent use of maladaptive behaviors, it is certainly plausible

that maltreatment and psychological symptoms were underreported. More recently, it has been

suggested that the YSQ-SF measures only the schemas an individual is aware of and therefore

schema avoidance or the coping responses activated by particular schemas may influence

responses (Thimm, 2010). Finally, the multi-collinearity present among the schema domains in

particular, may limit the predictive value of individual variables.

72

In addition to methodological limitations, the external validity of the findings is limited

due to the homogeneity of the present sample. Although it is important to examine these

relationships in a non-clinical sample given the limited empirical support within the literature,

results may not be generalizable to clinical populations, men, or more economically and

ethnically diverse samples.

Despite limitations, the present study attempted to provide a relatively parsimonious

integration of variables that have yet to be examined by previous researchers. Findings provide

preliminary support for the use of schema therapy with individuals endorsing an emotional

maltreatment history in an effort to prevent or reduce depressive and ED symptoms. Waller and

colleagues (2007) have initiated efforts to incorporate schema therapy into existing ED treatment

programs by providing recommendations for addressing the core beliefs that have developed in

response to emotional abuse. Suggestions include focusing on the Mistrust/Abuse and

Abandonment schemas that they theorize result from experiences of emotional maltreatment

(Waller, Corstorphine, & Mountford, 2007). Only one known study to date has attempted to

empirically investigate the use of schema therapy in ED treatment. Findings revealed that at the

end of a 6-month treatment program for individuals with a chronic history of Anorexia, no

significant changes on schemas were observed. Given the sample was limited to eight women,

further research is warranted. Notably, the authors suggested that patients’ ability to identify with

particular schemas (e.g., Unrelenting Standards, Defectiveness/Shame, Emotional Deprivation,

Emotional Inhibition, and Social Isolation) appeared useful is increasing their readiness to

commit to behavioral changes (George, Thorton, Touyz, Waller, & Beumont, 2004). Ultimately,

future research is needed to further clarify the relationship between emotional maltreatment and

ED symptoms in an effort to better examine the utility of incorporating schema therapy into

73

existing ED treatments. Given the chronic nature of eating psychopathology, particularly

Anorexia Nervosa, efforts to develop effective interventions are necessary given the treatment

resistance and relapse inherent in ED populations.

74

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